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Dental Anxiety and The Role of Providers in Facilitating Approachable Care

“I love our pediatrician, but I pray that he doesn’t leave our area because there are so many providers leaving,” said Rachel, a mother of two who lives in Wayne County, North Carolina. “It’s going to be hard for our family if he does.”

“For me personally, if my son were sick, I would not be able to get an appointment today. I would have to wait for an emergency appointment or take him to the emergency room,”
said Rachel. “We just have a lack of providers here, and we’re losing providers. They’re leaving our state to get paid better elsewhere, to get treated better elsewhere.”

Rachel’s sons have had Medicaid insurance for their entire lives, but Rachel herself went uninsured until recently. She qualified for Medicaid in 2020 after a severe case of COVID-19 that left her with long-COVID symptoms.

Gaining access to Medicaid insurance has allowed Rachel to focus on her own health, which she had to deprioritize partly due to the cost of accessing care without insurance.

“I wasn’t able to work much of the year as a result,” said Rachel. “So, I got Medicaid, and I didn’t lose it when I went back to work because of the pandemic supports. And I would have lost it if North Carolina hadn’t expanded Medicaid last year.”

Gaining access to Medicaid insurance has allowed Rachel to focus on her own health, which she had to deprioritize partly due to the cost of accessing care without insurance.

“I’ve transformed these past three years because I’ve finally been able to care for myself,” she said.

Rachel grew up with a single mother. Family financial constraints made dental care and primary care luxuries throughout her childhood. To get to where she is today, Rachel faced a long journey navigating a health care system often ill-equipped and, at times, seemingly hostile to her needs.

“I had to be very sick to see a doctor or dentist,” she said. “Even though I wasn’t seeing a dentist, I was very good about brushing. I wasn’t flossing like I should, but I was brushing. And what got me into it was preschool. They were all about dental care. They gave us visuals, and we brushed our teeth at school.”

In her early 20s, Rachel decided to see a dentist for the first time. Her wisdom teeth were causing pain and needed to be removed. She had never been to a dentist for a cleaning or any other service, but she had to address the pain she felt.

“The dentist referred me directly to an oral surgeon, and I will never forget how mean he [the oral surgeon] was,” said Rachel. “I think he thought I wanted pain medicine. I didn’t, I wanted to understand why I was in pain. I couldn’t eat, I was losing weight. And that experience scared me. I didn’t want to go back for that next cleaning with a dentist because of what I experienced with the oral surgeon.”

After that, Rachel avoided returning to a general dentist for her first cleaning. When she did make an appointment, her provider laughed at her for being scared in the office.

“At first I kind of brushed it off,” said Rachel. “But then they brought another dentist in, and one of them pointed at me and said, ‘Look how red she gets.’ I let them do the cleaning and fix one cavity, but I didn’t go back for several years after that.”

In 2020, Rachel needed to see a dentist again. She had an infected tooth that needed to be removed. She credits the dentist she saw then with helping her overcome her fear in dental offices.

“I said, ‘Would your staff be willing to talk me through everything? Walk me through it like I’m a toddler because I’m so scared,’” said Rachel. “The lady that he had assist him during the procedure had been through my experience herself. I thank God he did that because I needed someone with that experience to know what I felt.”

Today, Rachel and her entire family continue to see that same dentist. She credits his caring approach with helping her adjust to regular appointments and improve her overall oral health.

“After that experience, I stopped being scared of dentists,” she said. “I’ve been going to the dentist ever since.”

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Medicaid Expansion in North Carolina: April 2024 Updates

“Our partners in this effort helped us form one of the most unlikely bipartisan, cross-industry coalitions ever assembled in North Carolina–and we succeeded.”

— Care4Carolina Executive Director Abby Emanuelson speaking about Medicaid Expansion in North Carolina

Medicaid Expansion is one of the greatest public health achievements in North Carolina’s history, even though it is far from the end of the road toward truly healthy communities across our state. In honor of this week of recognition, we’re providing you with an update on Medicaid Expansion since it went into effect last December.

In this blog post, you can learn about the impact of Medicaid Expansion to date and considerations for oral health access and equity for newly eligible beneficiaries.

NC Medicaid Expansion

To recap, Medicaid Expansion extended coverage to people ages 19 through 64 years old who previously fell in the health care coverage gap, meaning they earned too much to qualify for Medicaid but too little to access the Affordable Care Act marketplace. Since expansion began on December 1, 2023, nearly 400,000 newly eligible recipients have already enrolled (about 1,000 daily), which is over half of the 600,000 expected to enroll over the next two years.

After launching Medicaid Expansion, NCDHHS, county health departments, and local social services departments have enrolled recipients faster than other states in the past (all states had the option to expand Medicaid beginning in 2014). Community-based organizations and partners have been essential in spreading the word and helping people enroll in the best plan to meet their needs.

NCDHHS Medicaid Data Dashboard

The NC DHHS Medicaid Expansion data dashboard provides monthly updates on how many people have enrolled through Medicaid Expansion, including statistics by health plan, demographics, and county. During a January 2024 interview, NCDHHS Secretary Kody Kinsley reported that Medicaid Expansion had already covered over $4.8 million in claims for dental services.

Highlights from the dashboard reports through March 2024 include:

  • New enrollees disproportionately live in rural communities (96,318 enrollees as of March 2024)
  • Over half of enrollees are under 40, with most between 19 and 29 years old
  • Anson, Edgecombe, Richmond, Robeson, and Swain counties have seen the highest enrollment rates

Oral Health Provider Shortage & Access to Care

While we celebrate the milestone achievement of NC Medicaid Expansion, we have more work to do. While North Carolina offers all Medicaid recipients oral health coverage, it is not currently listed as a benefit on the Medicaid insurance cards. Many people, from newly eligible recipients to health directors, remain confused about what Medicaid covers.

We also need more oral health providers who accept Medicaid to meet the growing demand. The physician shortage, especially in rural communities, affects beneficiaries and frontline workers alike. During our 2023 Oral Health Day event, keynote speaker Kathy Colville, former President and CEO of the North Carolina Institute of Medicine (NCIOM), put it clearly: “We have truly amazing and exceptional people holding up an inadequate system.”

Only 28 percent of dentists in North Carolina accept meaningful volumes of Medicaid patients. Of those who do, many accept just a few recipients and are not currently accepting anyone new. A contributing factor to this low acceptance rate is that Medicaid dental reimbursement rates remain at the same level as they were in 2008.

Long before NC Medicaid Expansion, dentists advocated for higher Medicaid reimbursement rates for oral health, which falls around 34 cents on the dollar today. Many more providers need to accept Medicaid to meet the demand. “They [Medicaid providers] are woefully underfunded,” said NCOHC Vice President Dr. Steve Cline.

Some estimates among oral health care providers suggest that reimbursement rates need to be at least 75 cents on the dollar to build an adequate private provider network to meet the need. Our incredible public health oral health providers do not have the necessary time, capacity, or resources to serve every Medicaid recipient in the state.

Unless our state and federal governments commit to a massive expansion of public health funding, we need private practice dentists to begin accepting new Medicaid patients as soon as possible.

What’s Next?

Alongside an overhaul of NC Medicaid reimbursement rates, as we continue to enroll communities across our state, we need to both incentivize and make it economically viable for oral and health care providers to practice in rural areas. One path forward is expanding loan forgiveness options for dental professionals in rural communities.

We must also continue to advocate for policies and programs to expand the use of teledentistry. To do this, we need a robust rural broadband infrastructure.

Last year, NCOHC partnered with the North Carolina Institute of Medicine, with support from The Duke Endowment, to launch the Oral Health Transformation Task Force. Their full report with recommendations to transform our current oral health system will be released to the public soon. Stay tuned for more information!

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Oral Health Care Integration Case Study Part I: Social Work in Dentistry

“I don’t just want whole-person care happening in the clinic, I want to see whole-person education as well.”

Research shows that up to 80 percent of a person’s overall health can be attributed to non-medical factors. These social determinants of health (SDOH)* pose intractable barriers for countless North Carolinians when accessing oral health care. Care integration has been shown to increase access and equity in oral health and benefit both patients and providers.

*Although still widely used, recently, there has been a shift in language from ‘social determinants’ to ‘social drivers’ of health. This change acknowledges that a wide range of nonmedical factors can impact a person’s overall health; however, they do not determine what a person’s health outcomes will be, but rather have the potential to drive them.

The University of North Carolina (UNC) Chapel Hill School of Social Work and Adams School of Dentistry (ASOD) partnered to provide dental and social work students with interprofessional workforce development and learning opportunities related to SDOH. Integrating dental and social work education provides students from both cohorts with invaluable experiences that they will carry into their future practices.

Jamie Burgess-Flowers, MSW, LCSW, Kelsey Yokovich, MSW, and Lisa de Saxe Zerden, MSW, PhD published a research paper titled “The social determinants of health, social work, and dental patients: a case study” to document the first-year implementation of this model at the dental school.

UNC Chapel Hill School of Social Work & Adams School of Dentistry

Dr. Zerden created the program, Burgess-Flowers served as the clinical social work faculty member, and Yokovich contributed as the final and only macro (aka community management policy practice) social work student. Burgess-Flowers built the program and established clinical workflows in the dental settings. When Yokovich joined, she helped develop the programmatic integration, conducted research, and attended the dental school’s research day.

Currently, Burgess-Flowers is an Assistant Professor and the Director of Integrated and Applied Behavioral Sciences at High Point University and Yokovich is the Community Voice Program Coordinator at the Foundation for Health Leadership and Innovation (FHLI).

Before leaving for High Point University, Burgess-Flowers wanted to document their work and hopefully contribute to creating more opportunities for social workers to integrate into oral health care spaces. Yokovich had social work experience as well as working in both oral health spaces and wanted to help develop a model for integrating the two fields.

Burgess-Flowers and Yokovich shared their experiences and vision for integrated care in oral health settings. Join us in the conversation…

Why is this topic important to you?

“I came from a primary care setting, and I was working in integrated care with patients. I thought to myself, ‘This is whole-person care,’ but I wasn’t asking patients about their oral health.” said Burgess-Flowers. “As social workers, we talk a lot about how people need to realize that the brain is part of the body. But we’re just as guilty of leaving out the mouth.”

“I worked in a dental office as a treatment coordinator and saw the lack of resources for folks who might not be able to go to different health care offices because they don’t have the time, transportation, resources, or financial means,” said Yokovich. “If you’re going to go into integrated care, it can’t just be physical, it can’t just be behavioral outpatient, it has to be the whole-health picture.”

Can you speak about the influence of SDOH on oral health disparities and the effectiveness of addressing them through social work integration?

“Dental offices are incredibly, historically, traumatizing and can be very over-stimulating for folks with trauma histories,” said Burgess-Flowers. “One thing I’m big on is being able to explain to [oral health providers] how social determinants of health relate back to something like filling a cavity or placing a crown. That is what dentists have been historically trained [to do]. They’re procedure-based, so they really want to know how what you’re talking about or offering to assist with has an impact on what [they] do or why a patient is here.”

“The demographic of oral health providers does not match the demographics of the United States at large. There’s a very stark contrast between those providing care and those receiving care,” said Yokovich. “Something that Jamie and I tried to do while I was at the dental school was educating oral health providers to think about these systemic issues a little bit differently because they’re the ones who are then going to be taking that into practice.”

How did you see care integration help both students and patients?

“It (dental-social work integration) opened so many doors for patients to receive referrals that they might not have been able to receive before,” said Yokovich. “And being able to express concerns about different areas of their lives as well, which is super interconnected and interwoven into their whole health.”

“We’re seeing less turnover, less no-shows,” said Burgess-Flowers. “We see a lot of improvement with dental students and learners, we see their perspective on patients change. We see their burn-out rates improve. We see them feeling like they have a team of people they can lean on and work with inter-professionally and not have to take everything on themselves.”

What ideal changes do you foresee in dentistry and social work?

“I would love to see the model be standard in dental education. I want to see more social workers, and not just clinical social workers, but also your macro social workers, in dental education,” said Burgess-Flowers. “I want dentists and dental hygiene folks in social work education. I don’t just want whole-person care happening in the clinic, I want to see whole-person education as well.”

“I would love to see buy-in from every aspect of oral health care, whether that’s from the dental education perspective or private practice. And I would love to see providers start getting credentialed with Medicaid and accepting patients who they would not have traditionally accepted in their past practice,” said Yokovich. “Having that foundational educational piece is going to be really important for shaping a generation of providers that think about the care of an individual as whole.”

How do you see this research contributing to your work moving forward?

Burgess-Flowers said, “This [role] really is a beautiful blend of being able to teach dental students clinical skills, communication skills, and being trauma-informed, all the way up to self-wellness, preventing burn-out, thinking about our community, the social systems, and racism, and all of the things that come into health care and interfere with patient outcomes being what we want them to be.”

“In a perfect world,” said Yokovich, “I would love to see integrated care across the board, but I think that just starts with us being advocates now where we’re at in order to make small systemic changes happen, so this paper kind of sets a foundation for hopefully this to be replicated at different schools across the United States.”

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

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Children’s Dental Health Post-COVID 19

Dental cavities and gum disease remain the two most common oral health conditions—and they are often preventable. Cavities are also the most widespread chronic childhood disease and can continue into adulthood. Dental decay and other oral diseases at any age impact quality of life, school and work performance, and ability to access various opportunities.

In addition to increasing the availability of school-based preventative oral health services, policy changes, such as expanding the scope of practice laws for dental hygienists, have been shown to increase access to care and improve outcomes for children.

According to the North Carolina Department of Health and Human Services (NCDHHS) Division of Public Health Oral Health Section’s The Tragic Truth: Children’s Oral Health Declines in NC Post-COVID report, school-based services may be the only option to access dental care for children who are most at risk for developing oral disease in North Carolina.1

Find out how the ongoing impact of the COVID-19 pandemic and what the report revealed about the state of oral health for North Carolinian children.

Lack of Access to Oral Health Services During the COVID-19 Pandemic & Beyond

During the COVID-19 pandemic, the American Dental Association (ADA) recommended that dental practices postpone optional dental procedures like routine cleanings to decrease the likelihood of spreading the virus. According to an ADA Health Policy Institute survey, in March 2020, 76 percent of dental offices surveyed were closed for everything except emergency services, 19 percent were fully closed, and 5 percent were seeing fewer patients.2

While closures were necessary at the beginning of the pandemic to protect patients and providers, we continue to see the negative effects of this prolonged period of dental practice closures and limited school-based oral health services on children and communities.

Ongoing & Exacerbated Racial & Socioeconomic Disparities in Oral Health

Oral disease continues to disproportionately impact certain racial and ethnic groups. According to the Centers for Disease Control and Prevention (CDC), “non-Hispanic Blacks, Hispanics, and American Indians and Alaska Natives generally have the poorest oral health of any racial and ethnic groups in the United States.”2

Overall, only 39 percent of children from families with lower incomes and those at higher risk of cavities have received dental sealants compared with 46 percent for children from families with higher incomes.2

The Tragic Truth Report by the NCDHHS Oral Health Section

A key role of the North Carolina Oral Health Section (OHS) is to monitor community oral health across the state. In November 2023, Jessica Scott-Jeffries, DHSc, RDH School Oral Health Coordinator and Osaremhen Ikhile, BDS, DrPH Oral Epidemiologist from the NCDHHS Division of Public Health Oral Health Section published their research findings in The Tragic Truth: Children’s Oral Health Declines in NC Post-COVID.

Annually, the Public Health Oral Health Section collects oral health data on kindergartners using the Basic Screening Survey (BSS). Oral health indicators used in the survey include:

  1. Untreated decay,
  2. Treated decay, and
  3. No decay experience.

The first two indicators help determine “how well communities can access and use dental services,” while the third indicates “how well the overall oral health system and other determinants of health support optimal oral health of communities.”

NC Children’s Dental Health Statistics Post-COVID-19 Pandemic

The NCDHHS Division of Public Health Oral Health Section found:

  • Untreated tooth decay in children is the highest it has been in five years.
  • Treated decay in children is the lowest it has been in five years.
  • No decay experience in children is the lowest it has been in five years.

Racial Disparities in Children’s Oral Health

In North Carolina, there has been a…

  • 3-fold rise in untreated tooth decay among Native Hawaiian/Pacific Islander kindergartners compared to Asian kindergartners with no increase in untreated decay.
  • 2.5x decrease in treated decay among Native Hawaiian/Pacific Islander kindergartners.
  • American Indian/Alaskan Native and Asian kindergartners had less treated decay.
  • 2.5x decrease in treated decay among Native Hawaiian/Pacific Islander kindergartners.
  • American Indian/Alaskan Native and Asian kindergartners had less treated decay.

Poor oral health significantly impacts overall health and these systemic oral health disparities must stop. Not receiving the oral health care that they need and deserve can negatively impact children throughout their entire lives.

Two important steps to address the negative effects of the pandemic we continue to see today include 1) increasing access to preventative oral health services through school-based programs and 2) scope of practice policy changes essential.

To learn more, read The Tragic Truth: Children’s Oral Health Declines in NC Post-COVID.

1The Tragic Truth: Children’s Oral Health Declines in NC Post-COVID
2Oral Health and COVID-19: Increasing the Need for Prevention and Access

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

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NCOHC’s 2023 in Review

As we step into 2024, we’re taking a moment to reflect on 2023 as we begin building on what we accomplished last year.

What a year 2023 was… Among many other headlines, one of the biggest for North Carolina was the passage of Medicaid Expansion, which finally went into effect statewide on December 1st. After more than a decade of advocacy from across our state, approximately 600,000 people who were living in the health care coverage gap are newly eligible for no- or low-cost health care.

Read what our Vice President of Oral Health, Dr. Steve Cline, had to say about Medicaid Expansion and the dental safety net.

2023 was also a big year for the North Carolina Oral Health Collaborative (NCOHC) and our incredible coalition of oral health advocates. NCOHC transitioned to new leadership as Dr. Steve Cline took over as the Vice President for Oral Health at the Foundation for Health Leadership and Innovation (FHLI) and Crystal Adams was promoted to the Director of NCOHC.

As we look back at what we achieved together, we are also thinking about how we will continue to advance oral health equity in 2024 and beyond.

We are thrilled to announce that we received our largest ever grant–$1.8 million over two years—from the Blue Cross and Blue Shield of North Carolina Foundation. This will support our work influencing policy, developing and promoting workforce strategies, elevating partnerships, and engaging with communities across North Carolina.

Moreover, it will enable us and our partners to advance the recommendations from the North Carolina Institute of Medicine (NCIOM) Oral Health Transformation Task Force Report.

We are also delighted to announce that The Duke Endowment—a longtime partner and supporter of our collaborative work—has continued to invest in oral health equity by awarding NCOHC a $1.2 million grant over the next three years. We are also grateful for the ongoing support of the Dogwood Health Trust and the CareQuest Institute.

With this funding secured, we will expand our programs and support a more accessible, equitable oral health ecosystem, especially for rural and other underserved communities across our state.

Read about our collective successes with our statewide partners and get a sneak peek of what’s to come in 2024.

2023 Legislative Breakfast

 

At the North Carolina Museum of History on April 26, 2023, the North Carolina Rural Health Association (NCRHA) and NCOHC, along with our partners and numerous legislators, met to discuss ways to address the growing health care needs of all North Carolinians.

We presented awards to impactful state leaders, including Representative Donna McDowell White (NC House District 26), Senator Jim Burgin (NC Senate District 12), Senator Jim Perry (NC Senate District 2), Dr. Amanda Stroud (Dental Director, AppHealthCare), and Michelle Fortune (CEO, St. Luke’s Hospital).

Additionally, NCOHC announced its legislative priorities for the 2023-2024 legislative session, which include:

  1. Enacting a state budget to allow House Bill 76 (Medicaid Expansion) to take effect — we did it!
  2. Creating a Rural Areas Forgivable Loan Pilot Program to encourage dentists, hygienists, and assistants trained in North Carolina to stay and bring more providers to rural communities by adding funding for dental staff loan forgiveness.
  3. Promoting legislation to allow all dental staff to practice at the full scope of their training and licensure (e.g., removing regulatory burdens for hygienists and assistants).

Along with that, the North Carolina Rural Health Association, another FHLI program, announced its 2023 legislative priorities, which included 1) Medicaid Expansion and access to care, 2) health workforce pipeline, 3) maternal and child health, and 4) broadband for all.

Oral Health Day 2023: Challenges and Opportunities for the Dental Team

On June 21, 2023, we hosted Oral Health Day 2023. The theme for this year’s event was, “Challenges and Opportunities for the Dental Team.” Kathy Colville provided a keynote speech and panelists brought expertise and ideas for how North Carolina can become a healthier, more equitable state.

“We have truly amazing and exceptional people holding up an inadequate system,” said Colville, President and CEO of the North Carolina Institute of Medicine (NCIOM). She also spoke about the necessity of a systems-level approach to improving oral health and how integral oral health is to many meaningful aspects of our lives:

“The mouth communicates, eats, smiles, frowns, and makes silly faces. Our mouth and teeth allow us to show emotion, communicate our thoughts, and be human. With proper oral health, our mouth can do all of these things better.”

Other key topics discussed throughout the day included 1) Medicaid Expansion and dental reimbursement rates, 2) building community trust, and 3) advocating for and investing in an adequate, accessible, and equitable oral health care delivery model throughout North Carolina.

We hope you will join us for Oral Health Day 2024, which will be announced soon!

Community Oral Health Transformation (COrHT) Wrap-Up Convening

In October we joined forces with the Blue Cross and Blue Shield of North Carolina Foundation and the CareQuest Institute for Oral Health to host a final COrHT Initiative convening. The two-year initiative launched in 2022 to help safety-net practices pilot a value-based care payment model, following CareQuest’s “three-domain framework” that includes:

  1. Tele-prevention (teledentistry)
  2. Minimally invasive care (non-surgical treatment of disease)
  3. Integration of oral health with overall health care

The initiative was so successful that we are excited to announce it will continue to live on! 2023 was originally intended to be the final year of the initiative, but at the 2023 convening every participating site agreed to stay involved and keep the initiative going.

We look forward to continuing to collect data, coach providers, and help explore avenues to transition to a value-based oral health system.

Western North Carolina (WNC) Oral Health Convening

We facilitated a WNC Oral Health Convening at the Lake Junaluska Conference Center in Waynesville this year with support from the Dogwood Health Trust. Dedicated oral health leaders working directly in small towns and rural communities throughout the Appalachian region came together for an engaging discussion about access to care, the current dental workforce, and policy priorities.

Following the sale of Mission Hospital to HCA Healthcare, NCOHC stepped in to help continue the convening of a WNC Steering Committee that formerly worked through the Mission Hospital Children’s Dental Clinic.

The goals of the committee and ongoing convenings are to 1) increase health care integration by facilitating collaboration among dental, medical, and public health providers, 2) expand access to oral health care for rural and other underserved communities, and 3) enhance oral health literacy for families, policymakers, and providers, and more.

Oral Surgery Mini-Residency in WNC

NCOHC partnered with the Mountain Area Health Education Center (MAHEC) to launch a mini-residency program at their WNC facilities. The goal was to better equip oral health safety-net providers in the region with the skills to meet people’s comprehensive oral health care needs, rather than referring them to an outside specialist.

The first cohort of four safety-net dentists received hands-on complex surgeries training. There is a severe shortage of specialty and surgical oral health care available to uninsured North Carolinians or those with Medicaid insurance. By “training up” already qualified providers in safety-net settings, people who would otherwise be left without options will be able to access the care they need and deserve.

Patient Advocate Pilot Program

This year marked year two of the Patient Advocate Pilot Program. Four dental practices in the WNC region hired patient advocates, employees who help people navigate the system and access the entire spectrum of health services, including oral health care.

NCOHC provided training and ongoing support, and we are continuing to collect data from the patient advocate pilot. Ultimately, we will use this information to analyze the effectiveness of the program, which will wrap up in 2024.

Participating sites include Mountain Community Health Partnership, Blue Ridge Health, MAHEC Dental Health Center and Center for Advanced Training, and the ECU Community Service Learning Center in Sylva, North Carolina.

2024 Preview: What to Expect

NCIOM Oral Health Transformation Task Force Recommendations

In January 2022, NCIOM and NCOHC launched the Oral Health Transformation Initiative, a multi-sector task force to evaluate, assess, and make oral health system transformation recommendations. More than 70 key oral and health care stakeholders, policymakers, academics, and other influencers have contributed through collaborative design to identify critical oral health opportunities in North Carolina.

The task force will release an Oral Health Transformation Task Force Recommendations Report by February 2024. The report will cover issues ranging from payment and benefit design to care integration, pathway development, and consumer experience. It will also lay out a path forward to implement key policy priorities to improve access and equity in oral health care across North Carolina.

Portrait of Oral Health Report

As we have done in the past, NCOHC engaged with UNC-Chapel Hill MPH capstone students throughout the year, enabling them to gain hands-on experience synthesizing data and interviewing key stakeholders to develop an informative report about the status of oral health in North Carolina.

This year, a group of four students are still dedicating their time, energy, and talent to put together the Portrait of Oral Health 2024. This report will be an updated version of the original Portrait of Oral Health [PDF] published in 2017 by a group of oral health professionals, government officials, and community-based organizations.

Join Us on the Road to More Equitable Oral Health Across NC

With 2023 swiftly falling into our rearview mirrors, we feel deeply grateful for the dedicated partnerships and collaborative efforts we have had the privilege to be part of. As we enter a new year, we feel excited about embarking on the open road ahead together.

Our team will continue to advocate for and advance policies and initiatives that create a healthier, more equitable oral health landscape for every North Carolinian. Stay tuned for details about events like this year’s Legislative Breakfast and Oral Health Day.

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

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Medicaid Expansion in North Carolina – What You Need to Know

Medicaid Expansion finally took effect statewide on December 1st, 2023, thanks to over a decade of advocacy by countless organizations and individuals. All of us here at NCOHC and the Foundation for Health Leadership & Innovation (FHLI) are thrilled to see this important step forward for North Carolina take effect, but we will also continue working hard to improve health access and equity for all North Carolinians.

Medicaid Expansion is expected to provide over 600,000 people in the health care coverage gap, including veterans, frontline workers, small business owners, parents, and many more, with access to health insurance. This includes residents with incomes too high to qualify for Medicaid but too low to receive health care subsidies through the Affordable Care Act marketplace.

This insurance will include comprehensive health coverage, including dental, behavioral health, and vision care.

Find out whether you may be eligible for benefits and what Medicaid Expansion means for rural and other underserved communities across our state.

FAQs About Medicaid Expansion in North Carolina

Here are answers to some frequently asked questions about Medicaid Expansion in North Carolina effective December 1st, 2023:

Who is eligible for Medicaid Expansion in NC?

Most adults ages 19-64 who earn up to 138% of the federal poverty line (e.g., singles earning about $20,000/year or families of three earning about $34,000/year) may be eligible. Read more about eligibility requirements.

How can I apply for Medicaid in North Carolina?

Applying online through ePASS is the quickest option. For a step-by-step tutorial, watch this how-to YouTube video from the NC Department of Health and Human Services (NCDHHS). You can also apply in person, by phone, or by mail.

How long will it take for my Medicaid application to be processed?

It may take up to 45 days (about 1 and a half months) for your application to be processed. Apply today to access your benefits as soon as possible.

What does Medicaid health coverage include?

Medicaid includes primary care, hospital stays, maternity care, vision and hearing, dental/oral health care, and more.

What does Medicaid pay for?

Full Medicaid health care coverage pays for your doctor visits, yearly check-ups, emergency care, mental health, and more. There are no monthly fees and copays are never more than $4.

What Medicaid Expansion Means for Rural & Underserved Communities in NC

The 2023 North Carolina Rural Health Snapshot [PDF] report compiled by the North Carolina Rural Health Association (NCRHA), an FHLI program, shows that rural residents are 40% more likely to be uninsured and eligible for Medicaid Expansion.

It is expected to create an estimated 37,200 jobs, generate thousands in savings for small businesses, and bring billions of dollars in federal funding back to North Carolina annually. In addition to strengthening our economy, it will help our communities become more resilient and increase access to timely, affordable health care.

According to the NCRHA’s sweeping analysis, previous studies also show that Medicaid Expansion is associated with improved hospital financial performance and fewer hospital closures. Since 2010, when Medicaid Expansion first became an option for every state, seven rural hospitals have closed in North Carolina. We need to rebuild and expand the rural health infrastructure to effectively serve our rural and other historically underserved communities.

As hundreds of thousands of people gain access to coverage through Medicaid Expansion, we must continue to work at every level to create a more accessible and equitable health care system. This means expanding the number of culturally competent providers who accept Medicaid insurance for all types of care, including oral health and specialty services.

Stay Tuned for More on Medicaid Expansion in North Carolina

FHLI and all our programs will continue to advocate for all North Carolinians and leverage policies that increase health care access and equity across our state. While Medicaid Expansion is an important win expanding access to care across our state, much work will still need to be done to ensure those who gain coverage have access points to receive quality care.

Follow us on social media and sign up for our newsletter to stay up to date about Medicaid Expansion.

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What is Myofunctional Therapy

 

At the 2023 NC Dental Hygienists’ Association Annual Session, Christina Bridges, QOM, LMBT, owner of Myofunctional Matters Therapy Partners, presented about myofunctional therapy. NCOHC sponsored the event, which provided hygineists from across the state with opportunities to gather, share ideas, and learn about new and interesting advancements in oral health.

Although highly relevant to oral health, you may be wondering, what is myofunctional therapy?

In Christina’s words, “myofunctional therapy is physical therapy for the muscles of the tongue, face, lips, throat, and soft palate to treat dysfunction.” It retrains muscle function in these body parts, which make up the orofacial complex.

Integrating Oral & Whole-Body Health

Christina noted that medical and dental professionals tend to treat the body and mouth separately. Yet, integrating and coordinating services is crucial to increasing access and equity in our health care systems.

She said, “As dental professionals, we can get so accustomed to seeing things through our own lenses that we forget to look at the person as a whole. We are intricately made beings and no system in the body works in isolation. Myofunctional therapy is a magical place where medical and dental professionals come together in true preventive care. Patients win when we collaborate!”

Benefits of Myofunctional Therapy for Patients

In her practice, Christina uses myofunctional therapeutic techniques as well as massage and bodywork to help patients with orofacial myofunctional disorders (OMDs). A few examples of OMDs include tongue ties, functional airway obstruction, mouth breathing, temporomandibular joints (TMJ) pain and discomfort, and many more.

Christina said the benefits of myofunctional therapy vary depending on the patient’s age and OMD. It can help children address issues early and prevent them from escalating into more serious problems. It can also help teenagers and adults find relief from pain and discomfort:

Benefits for Children

Benefits for Teenagers & Adults

  • Correct craniofacial growth/airway development
  • Improve sleep quality (can also improve behavior and school performance)
  • Stop bedwetting, snoring, sleeping walking, and night terrors
  • Reduce dental decay and improve diet due to increased willingness to try new foods
  • Prevent orthodontic relapse/eliminate need for orthodontics
  • Improve nasal breathing and sleep quality (can also increase energy)
  • Improve or eliminate TMJ pain or discomfort
  • Reduce sleep apnea/hypopnea events
  • Reduce/stop bruxism (teeth grinding)
  • Improve periodontal stability of teeth
  • Prevent orthodontic relapse
  • Improve ease of swallowing
  • Reduce gag reflex sensitivity
  • Reduce muscle tension in the head/neck

Life-Changing Outcomes: Myofunctional Therapy Success Story

Screening for myofunctional disorders can help connect patients with life-changing care. The right treatment can enable patients to speak, smile, and feel more confident, reduce pain, and improve quality of sleep, breathing, eating, and overall health.

One of Christina’s patients, a male teenager named Joseph, was originally referred to an orthodontist due to an undiagnosed and untreated tongue tie. He felt tired all the time and had difficulty waking in the morning. When Joseph came to Christina and her team, they quickly diagnosed the issue and performed myofunctional therapy as well as a tongue tie release.

Afterward, Joseph’s mother reported that he sleeps better now, has more energy, and is alert, calmer, and more productive. His posture has also improved; he stands up straight, whereas before he hunched over and had to push his chin out to breathe. For Joseph, and many patients like him, myofunctional therapy has improved his quality of life in meaningful ways.

Telehealth Myofunctional Therapy

Myofunctional therapy can also be done via telehealth. This can help reduce certain barriers like long journeys and wait times. However, many patients still face challenges related to internet access and reliability due to limited broadband infrastructure in rural and other areas.

According to Christina, telehealth works well for older children and adults. She says the same process can be performed as in an office setting. Telehealth is difficult for young children, though, who see better results with in-person sessions. Currently there are only a few myofunctional therapists in NC, making telehealth a vital option for age-appropriate patients.

Barriers to Accessing Myofunctional Therapy

Christina says, myofunctional therapy is rarely covered by insurance, especially when performed by those with a dental background. Unfortunately, prohibitively high costs leave many patients without a way forward. Her hope is that one day these services will be covered by dental or medical insurance. However, she sees great value in dental professionals providing these services because of how it builds on oral health care expertise.

Screening Patients for Myofunctional Disorders

NCOHC’s Program Manager, Heather Edly, JM, RDH, BSPH, CHES, said there has been a spike in myofunctional disorders like TMJ pain due to stressors exacerbated by COVID-19. Often, the only option for dental hygienists is to recommend a mouth guard, which may fail to address the root cause.

Learning to screen for myofunctional disorders can help hygienists connect patients to other types of care and improve oral health outcomes.

Christina said, “Every hygienist should know the signs and symptoms of myofunctional disorders and how to screen for them. As the primary preventive oral healthcare professional, the dental hygienist is the perfect professional to do this. Addressing these myofunctional issues is often the most preventive service we can offer. This is because myofunctional therapy addresses the root cause of so many dental and health issues experienced by our patients.”

If interested, you can learn about key clinical markers for myofunctional disorders here. To stay current with oral health news in North Carolina, sign up for the NCOHC monthly digest newsletter today.

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North Carolina House Votes in Favor of Medicaid Expansion

For years, Medicaid Expansion in North Carolina has been health advocates’ proverbial white whale. When it comes to policy changes that could dramatically improve access and equity in health care across the board, Medicaid Expansion would be a huge step in a positive direction.

North Carolina has unfortunately remained among the 11 states across the country that haven’t expanded Medicaid since its enabling federal legislation, the Affordable Care Act (ACA), was signed into law in 2010.

A Fresh Opportunity for Medicaid Expansion

As the 2023-2024 legislative session kicks off, members of the state House of Representatives are striking a new tune. On Feb. 8, 2023, Three Republican representatives and one Democrat filed House Bill 76, which will expand Medicaid in the state if passed into law.

A bipartisan group of 49 legislators had signed onto the bill as co-sponsors. On Feb 15, the bill passed its first two votes in the North Carolina House before passing its third and final vote on Feb 16. Now, the legislation is in the North Carolina Senate’s hands. If it passes through the upper chamber, it will head to Governor Roy Cooper’s desk to be signed into law.

North Carolina is one of 26 states (including Washington, D.C.) to offer extensive oral health benefits to both children and adults with Medicaid insurance. Because of this, anyone who gains coverage under Medicaid Expansion would gain oral health benefits.

What is the Coverage Gap?

The ACA enabled Americans to purchase health insurance through a government-managed marketplace, known as the “exchange.” To qualify for health insurance and tax credits through the exchange, individuals or families must earn enough income to be at or above the federal poverty level (FPL).

In North Carolina, Medicaid insurance only kicks in at or under 42 percent of the FPL, meaning anyone between 43 and 100 percent of the FPL have no options for health insurance. This is the coverage gap.

For example, a single parent with one child would need to earn $18,310 per year to qualify for tax credits and health insurance through the exchange. If they earn less than $18,310 but more than $7,240, however, no insurance options would be available.

Source: Care4Carolina

Medicaid Expansion was a provision of the ACA. Unlike the exchange, expansion was made voluntary on a state-by-state basis. States that choose to expand Medicaid fill in that gap, offering Medicaid services to anyone up to 100 percent of the FPL.

By The Numbers: Expansion’s Potential for North Carolina Health

More than 500,000 North Carolinians stand to gain health coverage if Medicaid Expansion is passed. Of those who would gain coverage, more than three quarters are employed and one in three are parents.

Financially, North Carolina stands to gain significantly if it closes the health care coverage gap. By expanding Medicaid, North Carolina could:

Create 37,200 jobs

Bring $4 billion in federal funding into the state every year

Save businesses $1,685 in lost productivity per employee per year

A Long Road Ahead for 2023 Medicaid Expansion

Senate Majority Leader Phil Berger has signaled that his chamber may not be as eager to take up the House’s version of Medicaid Expansion. There are several provisions that appeared alongside expansion in a Senate proposal during the 2021-2022 session that are not part of this year’s bill.

As House Bill 76 moves through the chambers, elected officials will have several chances to add or amend the legislation’s text. The NCOHC team is tracking this legislation and will post updates as it moves forward, so be sure to stay tuned for updates.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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2022 Year in Review

Goodbye 2022, hello 2023! What a year…

From a loooooong midterm election season to the World Cup, inflation, the war in Ukraine, the continuation of the COVID-19 pandemic, and so much more, there has been a lot on our minds. So much so that it is difficult at times to remember the accomplishments we all certainly made throughout the year.

Here’s a snapshot of NCOHC’s 2022. Our coalition of oral health advocates accomplished a lot, but there is always more to do as we usher in 2023.

Oral Health Day 2022

We decided to go big for Oral Health Day 2022, tackling the topic, “Equity in Action,” to try and define how we can all work toward a more accessible oral health system.

Dr. Eleanor Fleming gave the keynote address, highlighting systemic factors that impact our teeth and the need for antiracist collaboration to overcome barriers to care.

Oral Health Day attendees heard from a lively panel featuring providers, payers, government, and community members discussing their personal experiences and paths forward toward an improved oral health system.

Oral Health Day 2022 was the first to span two days. On the second day, NCOHC invited all participants to a collaborative workshop where we worked together to identify actionable policy solutions to oral health inequities.

Altogether, we were beyond impressed with the engagement and collaboration we witnessed over the course of Oral Health Day 2022, and we are excited to see that groundwork come to fruition in the coming years!

Student Partnerships Galore

NCOHC was fortunate to work with so many incredible student interns this year. You’ve probably already seen some of their work, and you will continue to see their content published in 2023.

Amber Moholehski – Amber returned to NCOHC after a prior internship through Campbell University. This past spring and summer, she worked on analyzing the existing landscape for dental assisting education in North Carolina, identifying key needs and options for future policy advocacy.

Sydney Patterson – Sydney is a public health student at East Carolina University. She joined NCOHC this past summer to write blog posts about various oral public health topics.

Parth Patel and Nidhi Oruganti – Parth and Nidhi worked together this past summer to explore North Carolina’s Medicaid system and innovative ways to incentivize more private practice providers to participate. Both Parth and Nidhi are undergraduate students at UNC-Chapel Hill.

Bryan Francis – Bryan worked with us during her fall semester to expand upon Parth and Nidhi’s summer work. She focused on policy pathways to expand and enhance the existing dental safety net. Expect to see more from Bryan, Parth, and Nidhi’s work in 2023!

Campbell University 2022 Cohort – Every year NCOHC has the pleasure of working with a cohort of Campbell University public health students. This year, Austin Blake, Juniki Langle, Jordan Moseley, and Matthew Pacofsky worked with us to explore dentist-administered HPV vaccines.

COrHT Initiative

In 2022, NCOHC and the CareQuest Institute for Oral Health fully launched the Community Oral Health Transformation (COrHT) Initiative in North Carolina. With 14 clinics onboarded into the program, we are putting resources into communities across our state to explore a value-based model of care. We hope this initiative sets the stage for evidence-based policy reform to structurally improve access and equity in oral health care for everyone in North Carolina.

Oral Health Transformation Initiative

Beginning in January 2022, NCOHC launched another initiative in partnership with the North Carolina Institute of Medicine (NCIOM). The Oral Health Transformation Initiative is currently in its second phase, where a task force is engaging in a 12-month evaluation of oral health transformation models from across the United States.

You can expect this task force to wrap up its work in 2023, with a full report on its findings to follow.

Oral Surgery Mini-Residency

In a continued effort to better equip our existing oral health safety net providers to meet the comprehensive needs of the people they serve, NCOHC partnered with the Mountain Area Health Education Center (MAHEC) to launch a mini-residency program.

This program will “train up” existing safety net dental teams, equipping providers with the confidence to offer more complex surgeries themselves rather than referring patients to specialists. For uninsured people and those with Medicaid insurance, accessible specialist care can be incredibly difficult to find.

In 2023, the first mini-residency cohort will begin their studies at MAHEC’s western North Carolina (WNC) facilities.

Patient Advocate Pilot

NCOHC solidified the framework for its Patient Advocate Pilot Program, which will fully launch in 2023. Across WNC, four practices have worked with NCOHC to prepare contracts and set the groundwork to hire “patient advocates,” employees who will help people navigate the system and access the care they need.

Brush Book Bed

Wrapping up nearly two years of planning, NCOHC was able to launch a pilot Brush, Book, Bed program with five pediatric primary care practices in WNC. NCOHC and its partner organization, Reach out and Read, were able to provide thousands of books and oral health kits to these practices, which were trained to provide basic oral health education and fluoride varnishes to their early childhood patients.

The End of a Productive Legislative Biennium

2023 marks the beginning of a newly elected legislature in North Carolina. NCOHC is excited to build upon many legislative wins from the past two years, from Executive Order 193 authorizing dentists to join the COVID-19 vaccination effort to Session Law 2021-95 and the state budget’s extension of the North Carolina Medicaid for Pregnant Women (MPW) program.

In 2023, we look forward to working with legislative and advocacy partners to continue improving the oral health status of all in our state.

Looking Forward to 2023

As we reflect on 2022, we are humbled by the incredible partnerships and coalitions we have the opportunity to be a part of. Our goal is to create a North Carolina where everyone can access the care they deserve, and 2022 represented many steps in that direction.

There is still so much work to be done, but we are entering 2023 confident and energized for what is to come!

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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Thank you, Dr. Zachary Brian!

After four years as the director of NCOHC, Dr. Zachary Brian has taken the next step in his career.

Dr. Brian will join UNC-Chapel Hill with a dual appointment with the Adams School of Dentistry and the Gillings School of Global Public Health. While his time with NCOHC has come to an end, it is clear that his impact on oral health in North Carolina is far from over!

Since he joined FHLI in 2018, Dr. Brian has led the NCOHC team along with countless partners and advocates to policy victories that are actively transforming access to care in North Carolina. His leadership was fundamental in achieving regulatory rule changes allowing more children to receive preventive oral health care and passing landmark oral health legislation, making North Carolina’s dental landscape more equitable and accessible.

From key pandemic provisions allowing dentists to administer COVID-19 vaccines to recent expansion of North Carolina’s Medicaid for Pregnant Women program, the entire NCOHC team is incredibly proud of what our broad coalition has been able to accomplish during Dr. Brian’s tenure.

Dr. Brian’s impact certainly won’t end with his departure. This past year, NCOHC was able to launch several programs and initiatives that also promise to positively transform oral health access and equity. The COrHT Initiative, the Oral Health Transformation Initiative, Brush Book Bed, and the Patient Advocate Pilot Program are all ongoing projects exploring new and innovative ways to get care to those who need it most.

The NCOHC team is certainly sad to see Dr. Brian go, but we are also well-equipped to continue our important work as we head into the new year. Dr. Steve Cline, who has served on NCOHC’s advisory team and FHLI’s board, has stepped in as interim vice president of oral health. Crystal Adams, formerly our associate director, has received a well-deserved promotion to director of NCOHC.

We are incredibly proud of Dr. Brian. From the entire NCOHC team, thank you for your tireless work to improve oral health access and equity in North Carolina!

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.