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WHAT ARE THE THREE PROPOSED PROVIDER TYPES?

The PEW center on the states three provider types:

• Dental Therapists• Primary care providers of preventive and restorative

care for children• Introduced in 1921 in New Zealand and common in 53

countries• The two year program resembles the last two years of

dental school• In the U.S., utilized in Alaska’s tribal regions• Practice in satellite clinics under supervision of dentist in

hub clinic

WHAT ARE THE THREE PROPOSED PROVIDER TYPES? The PEW center on the states three provider types:

• Community Dental Health Coordinators• Proposed community health workers• Would complete 12 month training and 6 month internship

(required for dental assistants, EFDAs, RDHs, and CHWs)• Work under supervision of dentists to triage patients and

help them navigate health care system• Proposed by American Dental Association• As of March 2012, not accredited by CODA but hearings

are scheduled at the joint ADA ADAA Annual Session Oct 31 to Nov 3

WHAT ARE THE THREE PROPOSED PROVIDER TYPES?The PEW center on the states three provider

types::• Advanced Dental Hygiene Practitioners• Proposed as case managers and primary care

providers• Would provide preventive and basic restorative care• Would refer pts to dentists for more complex services• The ADHA has developed a master’s degree ADHP

program

WHAT ARE THE REASONS FOR PROPOSALS FOR NEW TYPES OF PROVIDERS?• High rates of untreated dental problems in low income

families, children, and minorities• Survey of families in 2003-04 showed that 18% of Latino children

and 16% of multiracial children had never seen a dentist• 80% of caries occurs in 25% of children, many from low income

families• Shortages of private dentists who participate in Medicaid

and CHIP• Only one in three children under Medicaid received dental care in

2006• States are required to provide Medicaid dental coverage for

children but NOT for adults (only 16 states provide comprehensive dental coverage and another 16 provide emergency care only to adults)

WHAT ARE THE REASONS FOR PROPOSALS FOR NEW TYPES OF PROVIDERS?• Community health centers and similar safety nets only reach

10% of those who need care• People without HEALTH insurance have bad teeth because going to the

dentist seems like a luxury when you are paying for everything out of pocket• When the economy is bad, optional benefits such as dental insurance

are the first to be cut by employers• Medicare does not include dental, so those over 65 must pay out of

pocket or forego dental care

• Recognition of new providers ability to provide high quality care• The current dental workforce does not meet the needs of special

populations, such as young children, the elderly, and those with disabilities• 93% of dentists are in private practice

HOW DOES THE DEMAND FOR CARE EFFECT THE PROVIDER SUPPLY?• Access to care in Massachusetts• In 2006, dental benefits through Medicaid were restored to

540,000 low income adults (eligibility expansion made this available to 140,000 more)• Waiting lists at health centers increased to 3 months or

more• Only 17% of the state’s dentists accepted Medicaid so the

wait list continued to grow• Providing access to care needs to be coupled with increased

availability of providers

WHAT OTHER DEMANDS WILL EFFECT SUPPLY?• Baby boomers are reaching retirement age with more of

their teeth, as opposed to the geriatric population 50 years ago

• By the year 2014, the number of dentists reaching retirement age will out pace the number of dentists graduating and entering the workforce

• Enrollment has dropped, from 6301 in 1978 to 4612 in 2004

• Almost 40% of dental graduates in 2003 were female, and female dentists were twice as likely to work part time & to do so for more years

• There is an uneven distribution of dentists: too few in rural areas and inner cities, and too few who care for children, the elderly, the disabled, and low income families

• The ADA report in 2005 did say that “public programs for dental services must have the necessary resources to translate unmet need into effective demand”

WHAT TYPES OF WORKFORCE SOLUTIONS HAVE BEEN PROPOSED?Simply expanding public insurance coverage will

NOT improve access to care; increasing the supply of providers must also be considered

Revamp dental school curricula to include community based settings/rotations

Offering repayment of loans to aid rural recruitment and retention

Increasing diversity in dental schools Using physicians and nurses to provide oral health

services to children

ARE THERE ANY ALTERNATE WORKFORCE SOLUTIONS?Research to Develop a New Provider type

Needs assessment and baseline data Who does not have access to care? What is the characteristics of

the population at risk? Where does this population live? Inventory of current infrastructure

Dental workforce inventory: Who is currently providing care? What are the providers

characteristics? Where are they practicing? Where are the shortages?

Educational inventory: Who are the eligible candidates? (recruitment and selection of

students), What is the capacity of the institutions? What are the quality assurance controls? (accreditation, licensure), How will the graduates be recruited for their jobs? How will efficiency of the process be assessed? (attrition rates)

ARE THERE ANY ALTERNATE WORKFORCE SOLUTIONS?Research to Develop a New Provider type

Delivery system analysis Can the current delivery system accommodate a new workforce

model? Where will the new providers be deployed? (school based clinics, nursing homes, community based centers) Will they be licensed to practice anywhere? (or only in shortage areas) How will the new providers be reimbursed? Will they require supervision from dentists? Do they need to have a network for referral?

Financial Resources Survey Who is covered by Medicaid and CHIP? What kinds of dental services

are covered? Would new providers be able to be reimbursed by these plans?

Political landscape assessment Who is likely to support or oppose the plan? What steps need to be

taken to get a new provider approved? (new legislation)

WHAT IS A DENTAL HEALTH AID THERAPIST?• Introduced in 2003 by the Alaska Native Tribal Health Consortium

• Alaskan native children 2-5 years old have five times the amount of tooth decay compared to other children in the U. S.

• Students are recruited from the area in which they will work, so they will be more likely to remain in that area and will be able to provide culturally competent care

• Upon completion of their two year program, they must spend 3 months or 400 hours working under the direct supervision of a dentist

• As of 2008, ten DHATs are providing care to thousands of residents in 20 villages

• University of Washington did an evaluation and found that high quality care was being provided and recommended expansion of the program

• DHATs scope of practice includes: dental screenings and assessments, taking x-rays and making diagnosis, applying sealants, fluoride, simple extractions and restorations. Complex cases are referred to the dentist.

WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR?• Developed by the ADA in 2006 in response to the dental therapists in

Alaska

• CDHCs would function as facilitators in communities, helping pts navigate the system, finding dentists who accept Medicaid, and providing education

• Would work under direct supervision of the dentist when providing direct pt care

• Certification, not licensure, would be required but this does not carry with it legal oversight, continuing education requirements, nor disciplinary power

• Scope of practice includes: assisting, applying sealants and fluorides, superficial scaling and polishing, and temporary restorations (hand instruments only)

• Two pilot projects were begun in California and Oklahoma where students would work with the Indian Health Service

• Program was designed by ADA and currently, is NOT accredited

WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR?• 12 month online didactic program through Rio Salada

College (Arizona)

• 6 month internship at the American Indian site and the urban site

• The pilot training program sites are: The rural site—University of Oklahoma. The hands-on clinical training will occur in Indian Health Service facilities, Tribal Clinics and Federally Qualified Health Centers.

• The American Indian site—A.T. Still University Arizona School of Dentistry and Oral Health (ASDOH) in Mesa, Arizona,

• The urban site—Temple University (Pennsylvania). The training for urban-based CDHCs will occur in Federal Qualified Health Centers

WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR?• The PA Dept of Health classified North Philadelphia as an area suffering

a shortage of dental health providers

• The ADA awarded a $1.14 million grant to the Maurice H. Kornberg School of Dentistry, Temple University

• in 2009 the school signed an agreement to become the urban site for the CDHC pilot program which would train 12 individuals from the community for this role

• Services to be provided included: screenings, fluoride treatments, sealants, and temporary restorations under remote supervision by dentists

• They will also help bridge the gap between local cultures and health care systems by helping patients gaining access to and becoming eligible for charitable dental programs

• The five year plan involves upgrading the school facilities and changing their approach to pt care to include more black and Latino populations

WHAT IS AN ADVANCED DENTAL HYGIENE PRACTITIONER?• Comparable to a Nurse practitioner or Physician’s assistant,

the ADHP would be a dental hygienist with a master’s degree who receives the additional training of a dental therapist

• This new oral health care provider has been developed by the ADHA

• Scope of practice would be preventive, diagnostic, and basic restorative to underserved populations in schools, nursing homes, community health centers, and dental clinics, under general supervision with standing orders from a dentist

• ADHPs will receive four to six years of education and be licensed

• Practice could involve either private practice or safety net clinics, where Medicaid would be accepted, increasing access to care and permitting the ADHP to treat pts and refer as needed to the dentist

• Practice could also involve general supervision in underserved areas

HOW CAN THE ADHP MODEL BE IMPLEMENTED?• Consensus building – keep stakeholders focused on

improving access to oral health to the underserved

• Legislation – work with the State Board of Dentistry to permit implementation of a new provider under existing regulations or enact new legislation to establish the new provider model

• Regulation – determine whether an existing board or a new board or committee needs to be established

• Education – curriculum development, funding, faculty training, accreditation

• System level changes – determine where new providers will work and develop business plans, marketing, contracts, collaborative agreements with dentists

WHAT ARE OTHER STATES DOING?

Tools for workforce development

California

• The Health Workforce Pilot Projects Program conducted evaluations to inform legislators about the strengths and weaknesses and how new providers would fit into the system.

• RDHAP was tested in1980 to teach new skills and expand the role of dental hygienists . In 1997, the new category was signed into law and 231 RDHAPs are in practice in California.

Colorado

• In 2008, the governor commissioned a study on expanding the scope of practice of advanced practice nurses, physician assistants, and dental hygienists.

• The report concluded that unsupervised hygienists can competently provide preventive services within their scope of training, education, and licensure.

WHAT ARE OTHER STATES DOING?

Tools for workforce development

Iowa

• The Bureau of Health Care Access in the Iowa Dept of Public Health was established to address overall health care planning, including oral health.

• Legislation in 2007 and 2008 has enabled data to be continuously gathered and reported to the governor regarding workforce recommendations, recruitment, and retention of health professionals.

Minnesota

• In 2008 the Omnibus Higher Education Policy Bill established the Oral Health Practitioner, similar to the ADHP.

• The Commissioner of Health and the Board of Dentistry met to make recommendations regarding the education, training, scope of practice, licensure, and regulation.

• In May 2009, the new provider was established and signed into law.

WHAT IS THE ADVANCED DENTAL THERAPY (MSADT) PROGRAM?Master of Science in Advanced Dental Therapy,

Metropolitan State University, Minnesota• The FIRST and ONLY Program in the U.S.

• Pre-requisite: Baccalaureate educated licensed dental hygienist

• Results in dual licensed, midlevel provider: dental hygienist and dental therapist

• Full time, graduate program, 44 credits

• Admissions criteria include: GPA 3.0 Current Minnesota RDH license with nitrous oxide and local

anesthesia certifications Prerequisite course – Restorative functions theory and lab

WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ?The science of health care delivery phase focuses on: Working within diverse communities Communication across cultures Understanding health care needs and the incidence of disease across populations Advancing safe, quality oral health care This phase has a total of 8 credits

The clinical practice development phase focuses on: Advancing assessment and evaluation skills and knowledge Simulation and clinical experiences Collaborative care provision skills unique to advanced dental therapy This phase has a total of 31 credits

The leadership and synthesis phase concentrates on: Extending health system and public policy knowledge Developing leadership skills A capstone project focused on the evaluation of a relevant clinical question This phase has a total of 5 credits

WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ?MSADT Inter-professional Didactic Courses

NURS 608 Epidemiology

NURS 605 Health Policy and Leadership

HSCI 648 Designing for Quality in Health Care

COMM 533 Theories and Explorations in Community-Based Intercultural Communication

These courses may be taken prior to or during completion of the MSADT competency-based dental courses.

WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ?) MSADT Competency-Based Dental Courses

DENH 610 Health Assessment and Oral Diagnostic Reasoning

DENH 620 Pharmacology Principles of Clinical Application

DENH 630 Management of Dental Emergencies and Urgent Care

DENH 640 Community-Based Primary Oral Healthcare I

DENH 650 Community-Based Primary Oral Healthcare II

DENH 660 Community-Based Primary Oral Healthcare III

DENH 670 Community-Based Primary Oral Healthcare IV

DENH 680 Community-Based Primary Oral Healthcare V

DENH 690 Advanced Specialty Practices

DENH 700 Advanced Community Specialty Internship

DENH 710 Comprehensive Competency-Based Clinical Capstone

WHAT IS THE EXPANDED SCOPE OF PRACTICE FOR ADVANCED DENTAL THERAPIST (MSADT) ?• Provide diagnostic services

• Formulate care plans

• Prepare and restore primary and permanent teeth

• Provide palliative therapy

• Emergency temporary placement of crowns

• Placement of preformed crowns

• Temporary restorations

WHAT IS THE EXPANDED SCOPE OF PRACTICE FOR ADVANCED DENTAL THERAPIST (MSADT) ?• Pulpotomies on primary teeth

• Direct and indirect pulp capping

• Prescribe medications

• Non-surgical extractions

• Identify orthodontic problems and refer

• Provide referral for dental tx beyond the ADHP scope of practice

WHICH PROCEDURES WILL THE ADVANCED DENTAL THERAPIST (MSADT) NOT PERFORM?• Perform root canals

• Prepare and place permanent crowns

• Prepare and place bridges

• Construct dentures

• Place dental implants

• Perform whitening or cosmetic procedures

• Preform surgical procedures

WHAT ELSE WILL IMPACT THE PRACTICE OF THE ADVANCED DENTAL THERAPIST (MSADT) ?• The ADHP is NOT an

independent practitioner• The ADHP works under

general supervision in collaboration with a dentist

HOW IS THE FIRST DENTAL THERAPIST IN MINNESOTA PRACTICING?• Works in collaboration with a dentist

• Makes about half of what the dentist makes

• Has approximately two more years of education than a hygienist but two less than a dentist

• Is licensed to replace crowns, extract teeth, and provide restorations

• Works in an office where 50% of the pts are low income

• Treats pts that many dentists will NOT treat because of the low reimbursement rates for pts on public assistance

WHAT MAY BE HAPPENING AT THE ADA / ADAA ANNUAL SESSION IN NEW ORLEANS?• CODA is NOT planning accreditation standards for a

hygiene based dental therapy program at this time

• CODA has a draft for accreditation standards for non-hygiene based dental therapy program

• Minnesota has a dual track program, legislative proposals for Washington and Vermont are dual track, and Kansas’ is hygiene based.

• Currently, the only state seeking dental therapy accreditation is Minnesota (the Minnesota Board of Dentistry has approved both the dental therapist and advanced dental therapist programs).

• The Commission needs to develop dental therapy standards for practitioners with a dental hygiene degree.

HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE?• 14 million children enrolled in Medicaid

did NOT receive any dental service in 2011

• In 22 states, less than half of Medicaid enrolled children received dental care in 2011

• A 2009 survey by the ADA revealed 37% of dentists are over age 55.

• ADA projects that between 2010 and 2030, the ratio of dentists to Americans will continue to fall

• Delaware has a dental shortage resulting in 21.9% of the population underserved

HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE?• Vermont and Maine each have over 48% of

their dentists over age 55 (NJ has 36% and NY 37%)

• By 2014, it is projected that the Affordable Care Act will provide dental coverage for an additional 19 million children BUT they will be entering a system that is unable to provide dental care for all the children with coverage

• Dentists reasons for not accepting Medicaid include low reimbursement rates and burdensome administrative procedures

HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE?• In NY, 57% and in NJ 51% of Medicaid

enrolled children did NOT receive dental care in 2011

• In 2009, > 830,000 Americans visited a hospital ER for toothaches

• Previously, in 2006, decay related ER visits cost $110,000 million

• Workforce Expansion:• 15 states, including KS, MA, ME, NH, NM, VT, and WA

are considering legislation to expand the scope of practice for hygienists and to license mid-level providers such as dental therapists

HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE?• A 2012 survey of deans of dental schools found that 75% thought that the scope of practice for hygienists and assistants should be expanded• Mid-level providers may make it financially feasible for private practice dentists to treat more low income patients• They may also serve in rural clinics, low income schools, and work with Telehealth Technology which links the supervising dentist to the mid-level provider• In Minnesota, dental therapists are employed in nonprofit dental clinics and community health centers• In Alaska, mid-level providers treat 35,000 rural residents

OUR FUTURE?

What should we be planning for New Jersey, New York, Pennsylvania, and Connecticut ?

REFERENCES

Advanced Dental Hygiene Practitioner (ADHP) retrieved 8/4/13 from http://www.adha.org/resources-docs/72612_ADHP_Competencies.pdf

Advanced Dental Therapy (MSADT) retrieved 8/10/13 from http://www.metrostate.edu/msweb/explore/gradstudies/masters/msadt/applying.html

Bebinger, Martha, (February 22, 2012) Dental Therapists Are Debated For Filling Coverage Gaps, Retrieved 8/10/13 from http://www.wbur.org/2012/02/22/dental-therapist-provider

Best Bachelors Degree in Dental Hygienist Schools - Rankings Table and Overview, retrieved 8/4/13 from http://graduate-school.phds.org/education-index/bachelors-in-dental-hygienist-degree-programs

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Cree, Renee, Dental Students and Faculty Work to Improve Oral Care in North Philadelphia

retrieved 9/8/13 from http://www.temple.edu/templemag/pdf/10spring.pdf

Crozier, Stacie, (November 30, 2009) ADA launches Community Dental Health Coordinator Pilot Program at Temple University, retrieved 8/10/13 from ADA.org

CDHC FAQS, (March 2012) retrieved 9/9/13 from http://www.ada.org/sections/educationAndCareers/pdfs/cdhc_faqs__final_march_2012.pdf

Dental report help wanted PEW, retrieved 8/4/13 from http://www.pewstates.org/uploadedFiles/PCS_Assets/2009/Dental_Report_Help_Wanted.pdf

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Ervin, Anthony J., What is an articulation agreement? Retrieved July 15, 2013 from http://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation-agreement.htmhttp://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation-agreement.htm

Featured Schools, retrieved 8/9/13 from PhDs.org. , Copyright © 1997 – 2013

In Search of Dental Care, The PEW Charitable Trusts, retrieved 8/9/13 from http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/In_search_of_dental_care.pdf

KEAN UNIVERSITY AND BERGEN COMMUNITY COLLEGE NURSING EDUCATION PARTNERSHIP PROGRAM 2012 – 2013, retrieved 8/9/13 from http://www.bergen.edu/pages1/Documents/81512_REVISED%20FINAL_COPY_OF_KEAN_BCC_ADMISSION_BOOKLET_R_MC_VH_111611.pdf

NJ College 2 College Transfer, retrieve July 15, 2013 from  http://www.njccc.org/college2college/4yearcolleges.html

REFERENCES

NJ State Board of Dentistry, Chapter 29, (August 7, 2012) retrieved 8/10/13 from http://www.njleg.state.nj.us/2012/Bills/PL12/29_.PDF

School of Health Related Professions, (March 2010) retrieved 8/9/13 from http://shrp.rutgers.edu/prospective_students/admissions/brochures_pdf/allieddental.pdf

Steinbach, P, and Lynch, A. (9/18/13), Talking Points, retrieved 9/18/13 from laquetiam@adha.net

Thomas Edison State College, Retrieved 8/9/13 from http://www.tesc.edu/ast/bshes/

TRANSFER ARTICULATION AGREEMENT BETWEEN COLLEGE OF COMMUNITY AND PUBLIC AFFAIRS DEPARTMENT OF HUMAN DEVELOPMENT BINGHAMTON UNIVERSITY AND BERGEN COMMUNITY COLLEGE (Jan 2010) retrieved 8/10/13 from http://www.bergen.edu/documents/articulation/SUNY%20Binghamton,%20Business.pdf