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Teledentistry in Action: Medical-Dental Integration at Greene County Health Care

In eastern North Carolina, Greene County Health Care (GCHC) is embracing teledentistry, one of many innovative steps they are taking to improve patient care and meet the needs of traditionally underserved populations.

“I think the thing that’s most exciting about teledentistry is the integration of medical and dental,” said Dr. Rob Doherty, chief dental officer at GCHC. “I’m looking at the patient and I’m talking to them face-to-face, and I also have that medical provider there in case there are questions.”

Dr. Doherty and Chi Nguyen, a physician assistant at GCHC, recently filmed a joint teledentistry appointment with a patient, which you can watch during Oral Health Day Part 2, a follow up to NCOHC’s annual oral health advocacy event. Learn more, register, and join the virtual event on October 23 from 1-3 p.m.

During a screening with Nguyen, the patient mentioned experiencing pain in his mouth. Rather than schedule a separate appointment with a dental provider, Nguyen was able to loop Doherty into the video call.

Picture of Dr. Rob Doherty talking to a patient via a computer webcam

Doherty consulting with Nguyen and her patient through GCHC’s teledentistry software platform.

“Chi had a patient on the line who she was just checking on. He had made a comment that he had a hard time sleeping because a tooth was bothering him, and it was a little bit swollen,” said Doherty. “So, she just sent me an email and I was able to speak with him face-to-face and really get an idea of what the problem was. I had the schedule right in front of me and I was able to get him an appointment at 2:30 that afternoon.”

Doherty said that the video call helped him get a much better idea of the problem, something he wouldn’t have been able to do had the patient just called in and said he had tooth pain.

“It is awesome, us being able to see a patient and have a three-way appointment,” said Doherty. “We can get so much done, we can be so convenient for that patient, and it’s just plain better care.”

Of the benefits that teledentistry provides, Doherty highlighted just how important time saved can be. Health centers like GCHC see large volumes of patients who otherwise wouldn’t have access to affordable care.

“Every time we open up a new site, we’re swamped,” said Doherty. “We have a long waiting list, and we have to limit the number of patients that we see.”

With technological innovations like teledentistry, providers can increase efficiency, provide care to more patients, and work through those waiting lists.

“I think the horizons are really opening up for us in teledentistry,” said Doherty.

Join NCOHC, Doherty, and the dental directors for Kintegra Health and Piedmont Health on October 23, 2020 to explore the many ways clinics in North Carolina are using teledentistry to improve patient care. At the virtual event, you will also hear from national experts, including the “father of teledentistry,” Dr. Paul Glassman, and more! Register today!

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Teledentistry in Action: Completing a Network of Care

Thousands of young children in the counties west of Charlotte receive annual dental care in their schools’ parking lots. With an active, and growing, mobile dental network, Kintegra Health’s Dental ACCESS Program is improving children’s oral health, and teledentistry is a vital piece of the puzzle.

On board one of Kintegra Health’s mobile buses, complete with three chairs, an x-ray room, and plenty of cartoons to keep children occupied.

“The program has just blossomed,” said Melissa Boughman, director of the ACCESS Program. “We have 60 schools that we work with now, and we saw 5,500 children last year.”

If schools remain open this fall and avoid COVID-19 outbreaks, the ACCESS Program is on track to see between 6,000 and 7,000 students this year, according to Boughman.

Students now receive temperature scans to screen for COVID-19 symptoms at the beginning of their visits to the Dental ACCESS Program.

“Parents working (with limited) access, specifically transportation access, means that parents sometimes can’t get to the dental office, or they can’t get time off of work to come to the dental office,” said Dr. William Donigan, dental director at Kintegra Health. “We need these children to get as much care as we can give them without the parents having to be here.”

“In Title I schools, transportation is such a major issue,” said Boughman. “It’s so wonderful that we’ve been blessed with these mobile dental units that we can drive right up, park, and they bring the children out to us.”

In one day at Battleground Elementary in Lincoln County, the hygienists and assistants on this mobile bus will see around 30 kids.

The ACCESS Program has two mobile dental buses, complete with three dental chairs and an x-ray room, as well as a dental van for follow-ups and dental sealants.

Once a child is on the bus, Kintegra’s dental team takes a series of nine photographs of the child’s teeth as well as x-rays, if necessary. While the dental hygienists and assistants can only provide preventive care on the mobile buses, the care doesn’t stop once a child goes back to class. Thanks to the Kintegra’s teledentistry software, those photos and x-rays are automatically uploaded, made immediately available to dentists and staff at one of their brick-and-mortar sites.

The computers on Kintegra Health’s mobile buses transmit data in real time to staff at clinic sites.

“Literally immediately, we can view all of that information at one of our sites,” said Donigan. “So, our Dental ACCESS Program navigators can then talk to the dentist and direct the parents to get the patient in for the care that they need.”

Dental navigators are another vital piece of the puzzle. Kintegra employs navigators to help parents and patients efficiently get the care that they need. For parents experiencing any of a slew of social determinants of health that make accessing care more difficult, having someone there to guide the process along can have a big impact on the care a child receives.

For more on dental navigators and how they increase access to care, check out a blog by one of our summer interns on community care coordination.

With a complete network, connecting the staff on Kintegra’s dental buses to the dentists at their clinic locations, children who may have not received care otherwise now have the opportunity to receive regular care.

“We see the difference in the children we have seen for many years versus the newcomers like the kindergarteners, and in some schools pre-k,” said Boughman. “When we see them yearly, we see a big difference. We also do education because we all know that education is the most important part of all of this. Once we clean their teeth (plaque and tartar) will come back quickly, but if we teach them how to take care of their teeth, they can have a lifetime of great (oral health).”

Want to see teledentistry in action?

Join NCOHC for Oral Health Day Part 2 to see how clinics like Kintegra Health use teledentistry to improve access to patient care. We just announced a change of plans. Instead of in-person tours, we will bring tours of clinics, including Kintegra Health, to you virtually on [DATE], along with a star-studded panel of teledentistry experts from across the country!

Learn more and register here.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Racism, Food, and Your Mouth: Parallels Between Food and Oral Health Equity

“Historic and systemic structural racism are inherent parts of the United States,” said Jen Zuckerman, director of strategic initiatives at the Duke World Food Policy Center. “This means every single system that exists within the United States is rooted, designed, and based in racism, and has been built on the system of oppression. Nobody alive today is to blame for the unfairness of our history, but we each hold a responsibility to create a better future.”

Continuing NCOHC’s series on the social determinants of health and how they impact equity in oral health, we spoke with Zuckerman to discuss how the Duke World Food Policy Center approaches inequities in food systems and the policy work that can make a lasting impact.

 

Click here for more on equity in oral health.

 

Access to food is an important social determinant of health, and healthy food options can significantly impact oral health. Unlike other posts in this series that directly break down relationships between the social determinants and oral health, this post will focus on food systems, underscoring how Zuckerman and the Duke World Food Policy Center are addressing inequities, while drawing parallels to oral health systems.

 

Oral Health Takeaway

Lack of access to affordable, healthy food options means consumption of less healthy food, often high in sugar and carbohydrates. This is an important concern, as these kinds of foods increase risk of tooth decay, gum disease, and other oral health issues.

 

The Center for Assessment and Policy Development defines racial equity as “the condition that would be achieved if one’s racial identity no longer predicted, in a statistical sense, how one fares.”

Racial inequity plagues food production, distribution, financing, ownership, and access in the U.S., so much so that Zuckerman said there is no true working example of an equitable food system. To understand the fundamental role that racism plays in creating systems of inequity, the World Food Policy Center looks toward ownership structures.

“An equitable food community is one where there is an equitable distribution of ownership as it relates to the ability to grow food, distribute food, and provide retail,” Zukerman said. “An equitable food community would also have equitable access to capital.”

 

Food Deserts vs. Food Apartheid

The Duke World Food Policy Center uses the term “Food Apartheid” to refer to areas with limited access to healthy food options. Food Apartheid broadens the conversation to include various factors and root causes of inequities in the food system such as historic disinvestment from communities of color.

 

The term “food desert” insinuates that the phenomenon is naturally occurring. Zuckerman pointed out that to truly understand the underlying structures that create food inequity, we must understand how points of limited access are influenced by generations of intentional disinvestment.

 

The ability — or lack thereof — to build generational wealth has been fundamental in creating inequities. According to the Duke World Food Policy Center, barriers to building generational wealth should also be front and center in policy work to address and reverse inequities.

“When we think about food, or when we think about anything in the United States, history has demonstrated that the white community has continually gotten investment through policies, programs, and initiatives,” said Zuckerman. “And communities of color have continually gotten programs and services, which do not build wealth.”

While programs and services for those who lack access are incredibly valuable, it is simultaneously important to take conversations of equity a step further to encompass the financial, policy, and power structures at play.

 

Oral Health Takeaway

What does ownership look like in the oral health space? According to a 2015 ADA report, 74.2 percent of licensed dentists are White, while only 3.8 percent are Black, 5.2 percent are Hispanic, 15.7 percent are Asian, and 1.1 percent are other non-White ethnicities.

 

Zuckerman pointed to housing as an example of racist policies that have created lasting impacts on generational wealth. White veterans returning from World War II were able to buy homes through the GI bill, while returning Black veterans were disproportionately blocked from homeownership due to redlining and other policies rooted in racism.

“Broadly speaking, instead of home loans, Black veterans got public housing from government support,” said Zuckerman. While policies like redlining are illegal today, “think about the wealth built over generations of homeownership versus the wealth you cannot build by living in public housing.”

 

Oral Health Takeaway

In North Carolina, the racial disparity among dentists is even wider. Around 82 percent of practicing dentists in North Carolina are white, according to a 2005 report from the UNC Sheps Center for Health Services Research. Which communities have been able to benefit most from generational wealth thanks to the dental industry, and which communities have not?

 

Racist policies, no matter when they were enacted or ended, have contributed to an historic disparity in wealth between white and BIPOC communities. Because of this, a lack of direct racism is not enough to reverse past racism. Whether we are aware of it or not, there are still people, policies, and structures in place today that have disproportionate negative impacts on communities of color.

So, how do we actually change racist systems and create equitable structures?

According to Zuckerman, ownership, which refers to both wealth creation and agenda setting, is a central piece of the puzzle.

“There need to be changes in financing and philanthropic investments,” Zuckerman said. “More philanthropic dollars need to be invested in BIPOC-led organizations, and those community organizations need to be able to set the agenda for what they would like their community to have.”

In oral health, significant focus is given to providing low-cost oral health services to those who have historically lacked access. While these programs and services are incredibly important, and this post is not in any way meant to downplay the hard work that so many people do to extend access, oral health champions can learn a lot from the Duke World Food Policy Center’s perspective.

As oral health policy champions, how can we help create more equitable structures that include a diverse workforce more representative of the population as a whole? Where is wealth being built in the dental industry, and how can we work to increase access to and equity in that side of the equation?

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Teledentistry in Action at Piedmont Health

“Technology has really changed the field of dentistry since March,” said Dr. Katrina Mattison-Chalwe, Piedmont Health’s dental director, referring to the need for dramatic shifts in how providers approach patient care to adapt to the COVID-19 pandemic.

As COVID-19 closed economies across North Carolina and the U.S., health departments and the American Dental Association recommended that dental providers reduce services to only treat patients with emergent needs. As a result, many practices and clinics began to re-think how they could use teledentistry to maintain patient care.

“When we were all confined to our homes and only able to come out for essential needs, teledentistry came into play,” said Dr. Mattison-Chalwe. “It has opened up our ability to treat patients—we are now able to talk with someone face-to-face without actually being face-to-face.”

 


 

While a full slate of dental services cannot be provided remotely—your dentist can’t reach through the computer screen to perform a filling—many diagnostic, education, and consultation services can be performed remotely, connecting patients to a provider for these essential services.

“Teledentistry has enhanced our abilities tremendously,” said Melvin Williamson, a dental assistant at Piedmont Health. “We are able to reach out to our community, especially the younger kids, who need help really bad right now.”

Remote care technology is also helping providers reduce the amount of time a patient needs to be in the office to receive care.

“Teledentistry has allowed us to triage our patients better,” said Dr. Lauren Harrison, a general dentist at Piedmont Health. “It has allowed us to screen our patients without exposing ourselves to anything that’s not necessary, and we’ve also been able to reserve more clinic time for patients who really need that time.”

Traditionally, dental care can require several appointments from start to finish, beginning with an examination, where a dentist and staff would assess the patient, develop a treatment plan, and schedule a follow-up appointment to deliver the care needed. With teledentistry, providers have been able to perform the initial examination remotely, minimizing the time a patient would need to be physically present in clinic.

Earlier this year, NCOHC launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation. The fund has helped award 20+ grants, including one for Piedmont Health, to purchase annual teledentistry subscriptions. These subscriptions will help health centers and other clinical facilities provide remote patient care both during and after the COVID-19 pandemic.

“We were not prepared for COVID-19. No one was. As a result of that, we didn’t have extra funds to be able to purchase teledentistry licensing for all our providers,” said Dr. Mattison-Chalwe. “The (NCOHC) Teledentistry Fund helped us purchase licenses for all 12 of our providers, so we are able to be on the teledentistry platform while we were all in quarantine, and we are still able to use it now.”

Want to see teledentistry in action?

Join NCOHC for Oral Health Day Part 2 to tour a Federally Qualified Health Center like Piedmont Health this October.

Learn more and register here.

Whether we meet in person or virtually, dental directors like Dr. Mattison-Chalwe will provide teledentistry demonstrations, highlighting remote possibility in oral health care, and answer your questions regarding its use or impact on community care.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Federally Qualified Health Centers: What Are They and Why Do They Matter?

It’s one of the most common questions in public health and the source of significant confusion in matters of health policy: what is a Federally Qualified Health Center?

Federally Qualified Health Centers, otherwise known as FQHCs, play an integral role in providing access to health care (including oral health care) in North Carolina and throughout the United States.

In this blog post, we will examine Federally Qualified Health Centers— what they are, how they are defined by the U.S. Health Resources and Services Administration (HRSA), and how they function as one of the most integral components of the dental safety net.

What is a Federally Qualified Health Center?

Federally Qualified Health Centers (FQHCs) are defined under federal laws governing Medicare and Medicaid. In the simplest terms, FQHCs are public health centers focused on serving at-risk and underserved populations. They offer access to comprehensive care regardless of a patient’s ability to pay and qualify for federal “Section 330” grants under the Public Health Service Act.

According to HRSA, FQHCs can take many forms, “including community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program ‘look-alikes.’ They also include outpatient health programs or facilities operated by a tribe or tribal organization or by an urban Indian organization.”

Although not technically federal programs, FQHCs are subject to criteria and rules established by the federal government and effectively function as a hybrid between a state and federal entity.

A more detailed explanation of what defines an FQHC is provided by HRSA. A full summary of HRSA criteria for FQHCs can be found on FQHC.org.

As defined by HRSA, FQHCs must:

  • Qualify for funding under Section 330 of the Public Health Service Act (PHS)
  • Qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits
  • Serve an underserved area or population
  • Qualify for federal malpractice insurance under the Federal Tort Claims Act (FTCA) for its providers and contractors.*
  • Offer a sliding fee scale
  • Provide comprehensive health care services (either on-site or through arrangement with another provider), including:
    • Preventive health services
    • Dental services
    • Mental health and substance abuse services
    • Transportation services necessary for adequate patient care
    • Hospital and specialty care
  • Have an ongoing quality assurance program
  • Have a governing board of directors

*Under the FTCA, health center employees and contractors are deemed to be federal employees.

The Impact of FQHCs on Health Care Access in the U.S.

FQHCs comprise a vital part of the “safety-net,” providing access to health care (including oral health care) for at-risk and underserved areas and populations.

As of July 2019, there were 1,368 Federally Qualified Health Centers in the United States. When combined with FQHC “look-alikes” ¬— organizations that meet the criteria for FQHCs but do not yet receive grant funding under Section 330 — and service sites, that number rises to more than 14,200.

FQHCs’ impact on access to health care for underserved populations is significant: according to HRSA, 1 in 12 people in the United States rely on FQHCs for care.

As reported by HRSA, the 28 million people served nationally by FQHCs include:

  • 1 in 9 children
  • 1 in 5 rural residents
  • 1 in 3 people living in poverty
  • More than 385,000 veterans

Between 2000 and 2018, the number of patients served by FQHCs increased 196 percent.

Graphic: "1 out of 12 people in th eUnited States rely on Federally Qualified Health Centers (FQHCs) for care"

The Importance of FQHCs in North Carolina

FQHCs also play an integral role in providing care to North Carolina’s underserved areas and populations. According to a report by Dr. Pam Silberman, professor at the University of North Carolina’s Gillings School of Global Public Health, as of 2017 there were 41 FQHCs with 216 service sites in North Carolina.

Together, these North Carolina FQHCs and look-alikes served more than 500,000 patients in 2016.

“Federally Qualified Health Centers touch so many lives here in North Carolina,” said Dr. Zach Brian, director of the North Carolina Oral Health Collaborative. “It is vitally important that their place in the safety net is understood, valued and recognized.”

Quote: "Federally Qualified Health Centers touch so many lives here in North Carolina. It is vitally important that their place in the safety-net is understood, valued, and recognized."

“FQHCs provide a vital service to North Carolinians,” said Dr. William Donigan, dental director at Kintegra Health, an FQHC in Western North Carolina. “These services include medical, dental, pharmacy and behavioral health. Our patients include Medicaid recipients, insured, uninsured and underinsured. North Carolinians deserve and need access to quality care and FQHCs provide the bulk of this care.”

The Bottom Line

So, what defines an FQHC? As with so many areas of public health, it’s complicated… but at their core, FQHCs represent a vital access point to health care for millions of U.S. residents, including hundreds of thousands of North Carolinians.

 

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Meet NCOHC’s 2020 Summer Interns

NCOHC has been fortunate to have two fantastic interns on our team this summer. Parker Norman and Emily Stallings are oral health advocates passionate about improving the lives of those who are traditionally underserved by health care systems.

Take a minute to learn more about them and why they chose to work with us at NCOHC!

Headshots of NCOHC interns Emily Stallings and Parker Norman

Parker Norman

Parker is an undergraduate student studying Health Policy and Management at the UNC Gillings School of Global Public Health with minors in Spanish and Entrepreneurship.

Fun Fact: “I hope to run a marathon on every continent and in every state! I am currently training for my third full marathon.”

Where did you first hear about NCOHC and why did you want to pursue an internship here?

“I attended a ‘Lunch and Learn’ about oral health policy in North Carolina through the Gillings School, which was led by the collaborative. I pursued an internship with the collaborative because I wanted experience in oral health policy, including research, and I wanted to engage in oral health advocacy activities.”

What about public health dentistry is intriguing to you?

“Public health dentistry is intriguing to me as it focuses on addressing the oral health of populations and the many determinants of health that influence each person to different extents, through many avenues including caring for vulnerable populations, policy research and implementation, research of health determinants and how to address them, and preventative education.”

What have you worked on as an NCOHC intern, and what do you hope to take away from this work?

“As an NCOHC intern, I conducted a literature review of dental care management models around the U.S., including dental navigator models and the ADA-formalized Community Dental Health Coordinator (CDHC) model. A dental navigator (or CDHC) is often a culturally competent individual from the communities served who focuses on connecting people with a dental home and the many things they need to obtain oral health care and maintain good oral health (i.e., transportation, insurance, health literacy perhaps with a translator’s help, preventative education among others).

“These models increase access to dental care through care coordination, resulting in better oral health outcomes. Through this work, I have come to understand how innovative oral health care workforce models can be utilized to address health determinants, like access to dental care, and improve the patient’s overall oral health outcomes. Conducting literature reviews to advise policy changes and advocacy efforts is a role I expect to engage in during my future career, and I am thankful for my experiences with the collaborative.”

If you could tell North Carolinians one thing you have learned that you think is important for everyone in North Carolina to hear, what would that be?

“I would tell North Carolinians that dental disease is entirely preventable. By focusing on prevention and addressing health determinants, everyone can have good oral health.”

What’s next for you?

“In the near future I plan to start my pursuit of a career in dentistry by attending dental school. I hope to study oral public health as I obtain my dental degree through a public health dual-degree program or public health elective courses.”

Emily Stallings

Emily is a second-year dental student in the UNC Chapel Hill Adams School of Dentistry. She graduated with a B.S. in Biology from Campbell University in 2019.

Fun fact: “I love traveling! I have traveled to seventeen different countries and all over the United States. I studied abroad twice, living in both Prague, Czech Republic and Genoa, Italy.”

Why did you choose to study dentistry?

“I’ve always enjoyed immersing myself in opportunities that place me at the heart of my community. Upon assuming the role of Student Clinical Assistant in the free Community Care Clinic at Campbell University, I encountered an overwhelming number of patients with poor oral health. This role allowed me to see first-hand how something so vital for life affects not only a patient’s physical health, but also their mental and emotional health. Compelled by the desire to make a difference, I decided to pursue a career in dentistry.”

Where did you first hear about NCOHC and why did you want to pursue an internship here?

“I first heard about the North Carolina Oral Health Collaborative as a first-year dental student when Dr. Brian gave a presentation in a class called, ‘Social & Ethical Issues’ taught by Dr. Lew Lampiris. After Dr. Brian shared that the collaborative was a dynamic organization that focused on oral health access barriers facing vulnerable populations across North Carolina, I knew that I needed to learn more about NCOHC as a future oral health care provider and community leader.”

What about public health dentistry is intriguing to you?

“Public health dentistry is fascinating. Each day is filled with patients of all ages from all walks of life and every day offers a new opportunity to educate each patient about the importance of oral health. Further, working at an FQHC allows all people, despite their income, to be treated. It truly is an amazing experience!”

What have you worked on as an NCOHC intern, and what do you hope to take away from this work?

“I have been working on a write-up that details the role of Expanded Function Dental Assistants in surrounding states with similar regional, social, and racial demographics to North Carolina. My research has allowed me to see just how restrictive access to dental care is and just how important health policy changes aimed at increasing access to oral health services can be at reducing the barriers that so many patients face.”

If you could tell North Carolinians one thing you have learned that you think is important for everyone in North Carolina to hear, what would that be?

“Your voice matters. By using your voice to bring attention to social issues you are passionate about, you can impact legislation, make positive changes in your community, and transform lives.”

What’s next for you?

“After graduating with my DDS in 2023, I plan to work as an associate in a rural, underserved area in eastern North Carolina with the hopes of one day owning my own practice. I am also very interested in advocacy, public policy, and public health dentistry, so I can’t wait to see what the future holds!”

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Flipping the Incentive Structure with Value-Based Care

Value-based care is coming to North Carolina. While dentistry may not be included in the first wave, oral health care providers should be prepared to make the transition sooner rather than later.

Given this reality, NCOHC will be launching a “value in dentistry” educational campaign in the coming weeks. This campaign will focus on giving both provider and consumer communities a chance to better understand how value-based care and associated payment restructuring in oral health care could work.

In 2015, the North Carolina General Assembly enacted a bill directing the Department of Health and Human Services (DHHS) to transition the state’s Medicaid program from its traditional fee-for-service model to Medicaid Managed Care.

While Medicaid Transformation — the name for the transition to Managed Care — is currently suspended due to the state’s ongoing budget stalemate, North Carolina is still on track to make the change in the coming years.

It is important to note that dentistry is not currently included in Medicaid Transformation. The federal waiver allowing Medicaid Managed Care expires in 2024, and dentistry should be prepared to be included during this time period or in subsequent rounds of transformation.

Simply stated, under Medicaid Managed Care, North Carolina will pay insurance companies a set rate per patient to provide all necessary services to those on Medicaid. This model isn’t exactly value-based care — we’ll get to that point later in this post — but it does signal a paradigm shift. Through Medicaid Transformation, the opportunity to innovate and launch value-based care and value-based payment models is ripe.

The traditional fee-for-service model of health care incentivizes more costly, invasive procedures, while Managed Care is meant to incentivize keeping patients healthy and out of the doctor’s office.

 

 

Now, before you get your feathers ruffled, we aren’t suggesting that fee-for-service payment models are some sort of conspiracy leading providers to direct patients toward more expensive treatments in the name of the almighty dollar. If you pull any medical or dental professional off the street and ask them why they chose their profession, helping people lead healthy lives is likely high up on the list. Yet, “healthy patient who needs nothing done” is not a billable procedure, even if it is the ideal outcome.

Under Managed Care, you can see clearly where the profit model incentivizes healthy outcomes. If insurance companies are paid a set rate per individual, the less work each individual needs, the larger the profit margin becomes.

Managed Care vs. Value-Based Care

Now, how is Managed Care different from — and similar to — value-based care?

First, both models focus on health outcomes rather than fees paid for services provided. While Medicaid Managed Care focuses the financial shift on health insurance companies, existing models for value-based care focus on payment reform at the provider level.

For example, “bundled payments” is one value-based care reimbursement model. Under the bundled payment model, a patient would pay a fee for an entire “episode of care,” instead of paying separate fees for every service provided along the way.

 

DentaQuest Value-Based Care Fact Sheet

 

Value-based care in oral health delivery redirects the focus from volume toward an emphasis on the overall oral health outcomes of a patient. A shift toward value in dentistry will help assist in achieving the triple aim of patient care: lowering costs, improving patient outcomes, and increasing satisfaction.

Through enhanced education and a stronger focus on preventive-centric care rather than an episodic, surgical interventionist approach, more patients may need less invasive work. This translates to more affordable care — care in which better health outcomes will be accessible to more people.

It is important to note that in order to achieve value in dentistry and incentivize the shift, payment reform must accompany this approach. We will be discussing payment barriers and further expanding upon value in dentistry in future posts, so stay tuned!

For more information, visit DentaQuest’s value-based care webpage. There you will find a plethora of resources for dental providers.

To learn more and get involved, be sure to sign up for NCOHC news.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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NCOHC’s Policy Brief: Workforce Utilization

The North Carolina Oral Health Collaborative (NCOHC) recently released its first policy brief. The document outlines changes to North Carolina’s regulatory framework that, if enacted, could significantly increase access and equity in oral health care.

Read the policy brief here.

In the coming weeks, NCOHC will publish a series of deep dives into each section of the policy brief to explain the details of each proposal and how each could improve care for underserved North Carolinians.

North Carolina’s oral health workforce faces a growing imbalance that unnecessarily restricts access to care. The dental hygienist workforce is growing, and North Carolina’s dental hygiene programs remain competitive and full. Unfortunately, the population of practicing dentists is shrinking as dentists age out and retire faster than new ones graduate and enter the workforce.

This is a serious concern, as many of the access gaps in North Carolina are driven by a lack of dentists in rural and already underserved areas. In a recent post, NCOHC found that every practicing dentist in North Carolina would need to see 4,080 patients every year just to provide all residents with standard cleanings and checkups, not including follow-up appointments or visits for fillings and other advanced procedures.

Graphic comparing the 4080 annual patients dentists in NC would need to see to meet demand versus the 3,505 nationwide average annual patient load

With these trends in mind, it is important that North Carolina leaders take steps to allow the oral health workforce to provide care more efficiently. The proposals in the Workforce Utilization section of our policy brief address five policy changes* that can help:

  1. Revise the two hygienist per dentist supervision ratio
  2. Revise supervision definitions, primarily looking at revision of “direct supervision”
  3. Expand delegated duties for hygienists
  4. Eliminate restrictions on hygienists’ delivery of local anesthesia
  5. Recognize and credential Expanded Function Dental Assistants (EFDAs)

*It is important to note that these proposals do not necessarily reflect NCOHC’s current policy priorities. Rather, they are evidence-based steps that, if implemented, would increase access and equity in oral health care for North Carolinians across the state.

Supervision Requirements

North Carolina is considered one of the more restrictive states for dental hygiene scope of practice parameters. The North Carolina Dental Hygiene Act restricts dentists in private practice from employing more than two dental hygienists at the same time, and it also requires direct supervision—the most stringent form of supervision in a dental office—for most tasks that hygienists are effectively trained to perform.

Easing restrictions to these supervision requirements could significantly increase care provided, especially in community-based settings like school-based clinics and long-term care facilities, where dentists may not always be available on site.

Graphic defining the levels of supervision defined in the North Carolina General Statutes

Source: North Carolina General Statutes Chapter 16

Fortunately, easing direct supervision requirements, and expanding the number of hygienists a dentist can supervise, are not new or unique approaches to expanding access and equity in care delivery. Many states across the country have taken these steps, and often these changes were enacted several years ago.

Earlier this year, North Carolina took one important step toward a more equitable oral health landscape by allowing public health hygienists to work outside of direct supervision and rather based on a written standing order from the supervising dentist. The 16W rule change was important, but it only applies in limited settings. Allowing the rest of the dental hygiene workforce to practice in similar settings by written standing order instead of with a dentist physically present on site could significantly increase how many North Carolinians receive basic screening and preventive dental services.

Revision of Delegated Duties

North Carolina’s regulatory framework prevents hygienists from performing several clinical services in which they are required to be learn in their dental hygiene programs. With a few updates to include duties commonly delegated to hygienists in other states across the country, hygienists could significantly improve care access to the underserved, especially in settings outside the traditional dental office.

Graphic from oralhealthworkforce.org laying out allowable tasks for dental hygienists by state

Source: oralhealthworkforce.org

The NCOHC policy brief’s proposals for additional duties for hygienists includes interim therapeutic restorations (ITR), which refers to a restoration placed on a tooth to prevent the progression of a cavity. ITR’s should be done only in specific cases, when the cavity or decay in question hasn’t progressed too far. You can further read about ITR’s in the American Academy of Pediatric Dentistry’s Policy Statement on their use.

ITR is proven to reduce levels of cavity-causing bacteria and is used mostly when treating children and infants, especially when full restorative care is unavailable, unaffordable, or needs to be deferred.

Map highlighting states in the US where dental hygienists are allowed to administer interim therapeutic restorations

Source: ADHA

When restorations or other surgical procedures are necessary, dental hygienists could improve efficiency in the dental office by administering local anesthesia, which they are provided the didactic training for in their dental hygiene programs but prevented from performing under North Carolina law.

Along with hygienists, dental assistants play important roles in the dental office, and they, too, could increase dental office efficiency if allowed to perform expanded functions. Many states credential Expanded Function Dental Assistants (EFDAs). This workforce receives additional training to perform certain restorative procedures, such as the direct placement and modification of restorative filling material.

Map highlighting states in the US where dental assistants can be credentialed for expanded restorative functions

Source: AAPD

Stay tuned as we break down the rest of NCOHC’s policy brief. To receive updates in your inbox, sign up for NCOHC news today!

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Healthy Oral Care at Home

As some states reopen, others pause reopening, and more consider shutting down again, figuring out what is and isn’t safe to do can feel like a nationwide game of “red light, green light.” In a recent Kaiser Family Foundation poll, 52 percent of adults reported that they or a family member had skipped a medical appointment because of COVID-19. Sadly, the most common appointment skipped was for dental care.

In North Carolina, many dental offices are still closed, and others are only open for emergency services or are limiting services as they reopen. If your dental office is open for full services, you still might choose to stay home if a family member is immunocompromised, or if you are concerned about North Carolina’s rising case count, which is regularly topping 1,000 new confirmed cases daily.

Regardless of the reason, if you or a loved one are staying home and have missed an appointment—or even if you have seen a dentist or will see one soon—here are some steps we all can take for better oral care at home.

Use Fluoride Toothpaste AND Mouth Rinse

While brushing your teeth alone is important, fluoride actually strengthens your enamel and in some cases can reverse early signs of tooth decay. Fluoride toothpaste can be used at all ages, but it is important to use the right amount.

Mind Your Peas and Q’s

Fluoride toothpaste can be used as soon as a child’s primary teeth have started erupting from the gums. Before age three, just use a smear of toothpaste, no more than the size of a grain o rice. Start using a “pea at three”—a pea-sized amount of fluoride toothpaste for children and adults ages 3 and up.

Figure displaying a smear of toothpaste for children under 3 and a pea sized amount for children and adults 3 and up

Source: American Dental Association

Remember that less is more. You really don’t need the long squirt of toothpaste covering the entire brush you may see on commercials.

Know the Basics of Good Brushing

The saying doesn’t go “close only counts in horseshoes and brushing your teeth.” Brush for two minutes to ensure that you hit every single tooth, even those back molars. Two minutes may feel like a long time, but it is necessary to properly brush all sides of all your teeth.

While brushing, makes you are you are using circular motions. Brushing with a sawing motion can actually harm your teeth by increasing abrasive removal of your enamel and potentially damaging your gums. You should only apply mild pressure to your brush, about the same amount of pressure you would use to write with a pencil. It might feel like you aren’t cleaning hard enough if you use less pressure, but that’s just another reason why the full two minutes is so important!

Last, but not least, don’t forget about your tongue. Bacteria and other germs can build up on your tongue and can contribute to tooth decay, gum disease, and bad breath. Brushing your tongue is an important part of maintaining good oral health.

Change your Brush Regularly

A picture of a frayed toothbrush, with bristles flattened and sticking out in different directions

When your brush becomes frayed, its time to replace it.

Most dentists recommend changing your brush every three months or when the bristles become worn down.

Floss Daily

Brushing thoroughly can clean three sides of your teeth, but brushing alone can’t remove plaque or bacteria in between your teeth. Adding floss to your routine is an extra layer of protection from cavities, tooth decay, and gum disease.

Check your Mouth Regularly for Signs of Oral Cancer

Oropharyngeal cancers kill one person every hour in the U.S. Fortunately, early detection significantly increases survivability. Self-exams for oral cancer warning signs are quick and easy, and they are an important component of a healthy oral routine.

Check out our recent graphic about oral cancer and HPV for self-exam guidelines.

A fact sheet with information about oral cancer and HPV

Click here for a full PDF to access any hyperlinks above.

Know How Your Food Affects Your Teeth

What we eat can seriously impact our oral health, even with good brushing habits.

A graphic of unhealthy food for your teeth: fast food, cereal, sodas and sugary drinks, candies, beer (especially when mixed with tobacco) and starches

A graphic of healthy food for your teeth: leafy greens, fish and lean meats, beans, nuts, seeds, milk and dairy, eggs, and tofu

To learn more and get involved, be sure to sign up for NCOHC news.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!