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Access Blog Equity Public Health

Envisioning Teledentistry in North Carolina

Let’s take a moment to review an all-too-familiar scenario for many North Carolinians.

Martha lives in rural Tyrrell County, North Carolina, where there are no practicing dentists. She works a full-time job while raising her two children. So, she decides against making the hours-long round trip to the nearest dental office one county over to receive a cleaning and checkup.

Let’s face it: for Martha, the cost of transportation, the dental service itself, and the pay lost while she is away from work make for a steep price for care. On top of that, she knows that she may have to schedule a follow-up visit—and take time off from work again, find someone to pick up her children from school again, pay for gas again—if she has any cavities that need filling.

So Martha waits.

Sadly, what started as a bit of sensitivity develops into an unbearable toothache, which lands her in the emergency department (ED). In the ED, she is prescribed an opiate to deal with the pain and an antibiotic for the infection, and she is told to “follow up with your dentist.”

In a month or so, however, Martha, like so many others, ends up right back in the ED when her infection, which has never been directly treated, flares up again

Martha isn’t alone in this situation.

This story is reality for hundreds of thousands of North Carolinians who, for various reasons, cannot access oral health care.

A Better Way: The Promise of Teledentistry

Teledentistry is a promising innovative tool that could play a critical role in increasing access, especially in rural areas like Tyrrell County.

What is Teledentistry?

The use of telecommunications for dental exams and assessments, consultations between dental providers, and direct education for patients, among other uses. Teledentistry is a treatment tool that has incredible potential for increasing access to quality dental care in communities that traditionally lack access, especially in rural areas without practicing dentists.

Imagine this:

The next time Martha winds up in the hospital for her toothache, she is connected with a dentist in Chapel Hill via a live video feed. A medical professional takes digital x-rays of Marhta’s mouth and uses an intraoral camera to allow the remote dentist to take a look at her teeth. The dentist quickly diagnoses her abscessed tooth, prescribes Martha the correct antibiotic to help fight the infection, and helps her schedule an appointment for treatment.

With her oral health issue resolved, Martha finally breaks the cycle of hospital visits that she would have otherwise endured.

While Martha had never seen a dentist up until this point, she has always kept up a good habit of visiting her local federally qualified health clinic for an annual checkup. The next time she visits, she learns that the clinic now offers asynchronous teledental services in partnership with East Carolina University.

Synchronous and Asynchronous Teledentistry

Synchronous is a fancy word that means “at the same time.” In synchronous teledentistry, a dentist is connected via a live video feed to review material, assess the patient in real time, and provide direct patient counsel, if needed.

Dentists who practice asynchronous teledentistry are sent diagnostic information such as digital x-rays and pictures from intraoral cameras to review at a later date, giving them time to look at all the material and put together a comprehensive treatment plan based on the patient’s unique needs.

Digital x-rays and pictures from an intraoral camera are sent to a dentist who works through East Carolina University. She reviews Martha’s records later that week. Fortunately, this time there is no need for further treatment, but the dental provider does advise that Marhta floss more regularly.

Martha’s children have also never seen a dentist. Luckily for them, a dental clinic was recently established at their school and a dental hygienist provides them the same asynchronous teledental services that their mother received at the medical clinic.

The hygienist provides Martha’s children with fluoride treatments, dental sealants, and a thorough cleaning. The dentist who reviews their digital x-rays and other diagnostic information determines that they have no cavities, but that they both do have moderate gingivitis. The hygienist learns that the two have had to share a toothbrush, so the clinic provides them with two new toothbrushes and tubes of fluoride toothpaste.

From in-school clinics to emergency departments, teledentistry is a promising asset that could significantly improve access and equity in oral health care across North Carolina. For families like Martha’s, simple diagnostic services completed through teledentistry could drastically increase tangible access points to dental services, and in return prevent significant oral health burdens downstream.

The Tools of Teledentistry

Teledentistry can seem daunting, especially when it comes to modernizing an office to meet the technological needs of remote care. Unlike many variations of telehealth, however, the tools of teledentistry are actually quite simple. The basic necessities are:

  1. A digital x-ray system

  2. An intraoral camera

  3. Electronic patient records

Most dental practices already use digital x-rays and intraoral cameras, and practices across the country are rapidly making the switch to electronic record-keeping. Compared to other telehealth services, the startup cost for teledentistry is relatively low.

By helping break the cycle of emergency department visits for oral health crises, medical costs for patients and the healthcare system as a whole could be significantly reduced. This is especially important in our rural communities. Cutting the uncompensated care costs burdening rural hospitals across the state could go a long way in attaining financial solvency. Additionally, inserting a dental professional into the hospital setting via teledental services could be an important way to combat the opioid crisis, reducing the number of unnecessary opiate prescriptions often given to patients with oral health emergencies.

Want to Know More?

NCOHC is taking a trip later this week to tour the state-of-the-art Center of Excellence for Telehealth at the Medical University of South Carolina. Stay tuned for our report from the trip!

Also, join us on June 3, 2020, for Oral Health Day! Oral Health Day is NCOHC’s annual advocacy event at the North Carolina General Assembly. This year we will focus our discussion on pathways to successful teledentistry in our state. Click here for more information and to register today!

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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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Access Equity Public Health Social Determinants of Health

Takeaways From the North Carolina Public Health Leaders’ Conference

The North Carolina Public Health Association recently hosted its 2020 Public Health Leaders’ Conference, drawing professionals from across North Carolina to discuss pressing issues and the public health landscape as we look ahead to 2030 and beyond.

In many ways, this year’s conference marks a turning point in North Carolina, so we sat down with Foundation for Health Leadership & Innovation President and CEO Anne Thomas to talk about the conference and her takeaways.

The theme of the 2020 Public Health Leaders’ Conference was “Shifting the Trajectory: Advancing Equity in Public Health.” According to Thomas, the importance of equity is not a new concept in public health, but the unified focus across public health leaders in North Carolina marks a promising change.

Putting Health Equity Front and Center

“We haven’t always spoken with the language of equity,” said Thomas. “I became a public health director in 1996, and we always talked about disparities, but the conversations used to be, ‘If we just tell people to change what they eat and how they live, they will be healthier.’ We can tell people how to be healthy, but if they don’t have insurance, transportation, or the proper food, and if we don’t address root causes like structural racism and poverty, we aren’t really going to make much of a difference.”

Thomas said that the intentional shift toward an equity-focused landscape in public health is significant. While disparities in health have always been a top priority for public health leaders, the focus has generally been from a clinical frame, leaving non-medical drivers like food, transportation, and housing out of the picture.

At the conference, the North Carolina Institute of Medicine (NCIOM) and the North Carolina Department of Health and Human Services (DHHS) unveiled their “Healthy North Carolina 2030” strategy, which lays out priorities to improve health in the new decade.

The focus on health equity and the overall drivers of health outcomes speaks to the new transformational vision for public health in our state to improve the health and well-being of all North Carolinians.

This excerpt from “Healthy North Carolina 2030” highlights non-medical factors like incarceration rate, reading proficiency, and suspensions as important indicators of health.

Using Social Determinants of Health to Understand Equity

Want to Know More About Social Determinants of Health?

Read our analysis of the most pressing systemic barriers to access where we break down how geography, income, language, race, and more can impact health outcomes.

To highlight health inequities, speakers at the conference discussed the importance of understanding and tackling non-medical drivers of health. Instead of simply treating patients, the speakers championed a more encompassing approach, understanding that health starts in homes, schools, and communities, not once you walk through the doors of a doctor’s office.

“The thing that has really changed is that we are talking about the non-medical drivers of heath, the root causes that have caused health inequities, and evidence-based strategies to address them,” said Thomas.

Thomas said that 20 percent of a person’s health is the result of clinical care, and 80 percent comes from other factors known as social determinants of health. To address that 80 percent, providers will pay attention to social determinants of health, and the health care systems will provide mechanisms to make things like food, housing, and transportation accessible to those who need them to be healthy.

Buying Health: Equity in Action

The concept of “buying health” is where equity becomes operationalized. Buying health refers to a value-based model where health outcomes are measured and paid for, versus the current fee-for-service model, where the cost of care is determined by the service(s) provided.

“Right now, if I go to the doctor, the office gets paid. It doesn’t matter if my health improves because there was an office visit,” said Thomas. “The concept of buying health means screening for these non-clinical factors, and if it is food that they need, or transportation, that food or transportation will actually be paid for.”

NCCARE360, a partnership between FHLI and the Department of Health and Human Services, was also an important topic of conversation at the conference, specifically regarding buying health. NCCARE360 is the first statewide network to unite health care and human services, using shared technology to coordinate person-centered care that provides for both medical and non-medical needs.

By the end of 2020, NCCARE360 will be available in all 100 counties in North Carolina.

Thomas said that buying health was an important topic at the conference, especially as North Carolina prepares for Medicaid Transformation, the state’s plan to transition from Medicaid’s fee-for-service model to “Medicaid Managed Care.” Under Managed Care, the state government will work with insurance companies to create a system that incorporates physical and behavioral health to address both the clinical needs and social determinants of health for Medicaid recipients.

“I feel like we are at a tipping point now,” said Thomas. “Equity is no longer something we just talk about. We are developing real strategies to achieve it.”

Our Oral Health Takeaways

The major themes of this conference—implementing equity, understanding social determinants of health, and transitioning towards value-based care—all apply to oral health care as well as traditional medical care. In fact, these new points of focus highlight the importance of breaking down the siloes that traditionally separate oral health from the rest of the body.

“This new focus is helping communities and providers realize that we really can’t separate the head from the mouth from the body, and we need to stop thinking in a siloed mentality,” said Thomas.
At NCOHC we believe that integrated care models that address all of a patient’s needs, incorporating oral health, medical health, and non-medical needs all under one roof, are integral in creating an equitable health future for all North Carolinians.

As we head into 2020 and plan for the decade ahead, we are excited to work hard to address social drivers of health and pave an equitable path to a healthier future for all 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!

Categories
Blog Equity Social Determinants of Health

Systemic Barriers and Oral Health Equity in North Carolina

There aren’t many people who really enjoy going to the dentist.

Who wants to have someone poking around in your mouth, drilling into your teeth, and telling you to floss more?

Reluctance to enter an uncomfortable setting is far from the only barrier keeping North Carolinians from going to the dentist. Hundreds of thousands of North Carolinians experience systemic barriers that keep them out of a dental chair.

The Foundation for Health Leadership & Innovation’s (FHLI) North Carolina Oral Health Collaborative (NCOHC) works to dismantle systemic barriers to oral health care, addressing social determinants of health to create a more equitable landscape for everyone in North Carolina.

Geographic Barriers

Where you live has a lot to do with how easy or hard it is to see a dentist. Five of North Carolina’s 100 counties are home to most of our state’s practicing dentists.

Did you know?

74 of North Carolina’s 100 counties are designated Dental Health Provider Shortage Areas (HPSAs).

So, if you are in Raleigh, you might have a choice between the dentist five minutes up the road and another one on the way to work, giving you the flexibility to fit oral care seamlessly into your schedule. But if you live in Tyrell County, you may have to plan an hour-long trip to access the closest dental office.

Income

Cavity fillings, tooth extractions, implants, and crowns can be expensive treatments, and hundreds of thousands of North Carolinians are uninsured. Without the means to access oral health care from childhood, low-income North Carolinians often don’t receive preventive treatment early on, leaving them at higher risk of negative outcomes later in life. Beyond oral health, this has far-reaching impacts that influence a cycle of poverty that is hard to escape.

Poor teeth, I knew, beget not just shame, but more poorness: people with bad teeth have a harder time getting jobs and other opportunities. People without jobs are poor. Poor people can’t access dentistry—and so goes the cycle.

Sarah Smarsh, “Poor Teeth”

Be sure to check out NCOHC’s Resource Center for more content, like the incredibly personal and compelling essay about poverty and oral care, “Poor Teeth,” by Sarah Smarsh.

Compounding Effects

These systemic barriers to oral health care don’t occur in a vacuum. They compound, making access harder and harder. Imagine the difficulty of seeing a dentist if you live in a rural community and must schedule an hour-long trip to access care. Now imagine how much harder that would be to fit into your schedule if you are working two or three jobs to make ends meet. What would you do if, on top of all that, the dentist doesn’t accept your Medicaid insurance, forcing you to budget time for a two- or three-hour trip?

On a positive note, North Carolina’s oral care Medicaid benefits are among the best in the country. Unfortunately, they are incredibly underutilized. 76% of North Carolina’s dentists are in private practice, and few accept Medicaid insurance, making it difficult to find an in-network provider.

Language Barriers

According to the Modern Language Association of America, nearly 900,000 North Carolinians speak a primary language other than English. Most of these individuals speak Spanish, but other primary languages include French, German, Chinese (including Mandarin), Vietnamese, Arabic, Korean, and more.

For non-native English speakers, and for those who may not speak English at all, understanding dental care, finding a dentist, scheduling appointments, and coordinating with insurance companies can be daunting tasks. Making it even more difficult is the fact that many dentists in North Carolina don’t have bilingual staff or translated paperwork.

For dentists, language barriers can pose issues regarding informed consent. Even with a translator present, ensuring that the patient truly understands a procedure can be a major concern for providers.

Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) have a higher chance of suffering from poor oral health for a variety of reasons. The IDD population often has a harder time finding transportation to and from a dentist, many are non-ambulatory, and physical ailments can inhibit good personal oral hygiene habits. In addition, most dentists don’t have training to provide services for those with special needs.

In the Community

NCOHC recently partnered with Campbell University public health students for a practicum experience in oral health. As part of the program, the students worked to incorporate oral health into Harnett County’s MedFest event, a program of Special Olympics North Carolina that provides medical services to Special Olympics participants.

Read more about the program in, “Building Oral Health Champions: Reflecting on a Semester with Campbell University Public Health Students” or watch our video spotlight on Campbell University.

These are just a few of the factors that impact the IDD community. For a more in-depth analysis, check out this 2018 study by the Eunice Kennedy Shriver Center on oral health care for adults with IDD.

Racial Disparities

Oral health outcomes and access to care differ widely along racial lines. Non-white North Carolinians are far more likely to have lower household incomes, and many live in “food deserts,” meaning they lack access to healthy foods. These factors affect oral health, as well as health in general.

According to the CDC, non-white Americans have higher rates of poor oral health, with the largest disparities occurring between 2-4 years old and 6-8 years old. Childhood tooth decay is a serious issue in minority communities, and it is an issue that continues to affect oral health and whole-body health throughout adulthood.

How Do We Address These Barriers and Achieve Oral Health Equity?

Achieving equity will take a multi-faceted approach, involving people in all levels of health care, community leaders, advocates, and more. NCOHC is partnering with innovative professionals to address needs, specifically working to increase North Carolina’s dental workforce, expand service areas in underserved communities, and increase accessibility to marginalized groups.

NCOHC is currently partnering with the North Carolina Dental Society to encourage a state-level rule change that would allow dental hygienists to provide critical preventive services in high-need settings. North Carolina is one of the most restrictive states for dental hygienists. This simple rule change will help better utilize North Carolina’s existing dental hygiene workforce, increasing access in under-served parts of the state.

Other avenues to increase equity include:

  1. Working with nontraditional organizations to increase access points outside of the traditional dental office (often known as a “dental home”). This means incorporting dental care in schools, nursing homes, primary care offices, and more.
  2. Coordinating with dental offices to provide translated consent forms, descriptions of procedures, and other helpful content to non-native English speakers and those who don’t speak English at all.
  3. Encouraging innovative ways to utilize the workforce with technological solutions like teledentistry.

Stay up-to-date by signing up for NCOHC’s newsletters, and if you are interested in becoming an NCOHC member for free, join us today!

Categories
Blog Equity

Equity in Oral Health: What Does it Mean?

What is Equity?

You may have seen the comic below, which depicts three individuals watching a baseball game over a fence. It’s a simple image, but it shows important differences between equality and equity.

In the first panel, everyone is given the same assistance. They are treated equally, each with one box to stand on. But, as you can see, the people in this situation do not start on an equal playing field, and the outcomes are inherently unequal.

To achieve the same outcomes—everyone enjoying the ability to watch the baseball game—the shortest person in the group needs an extra leg up.

In the second panel of this comic, the tallest person no longer has a box to stand on and the shortest person now has two. While the tallest person is not receiving any additional assistance, his ability to watch the baseball game has not been diminished. Since the shortest person has received additional assistance, all three are now able to experience the same outcome: enjoying the baseball game.

Equity vs. Equality

While equality means treating everyone the same, equity means providing everyone with the resources and assistance they need to achieve successful outcomes. Equal treatment is important, but in a world where we all are different, with different experiences, abilities, disabilities, and resources available for our use, we inherently need different things in order to be successful. Equity addresses our differences to ensure that all people, no matter where they start, can have the opportunity to achieve successful outcomes.

Oral Health Equity in North Carolina

The Foundation for Health Leadership & Innovation’s North Carolina Oral Health Collaborative (NCOHC) is working to change the conversation toward a focus on equitable oral health care.

North Carolina is experiencing an oral health crisis that is felt disproportionately across the state. NCOHC has identified several drivers of inequity, including long distances to reach the nearest dentist, high treatment costs (and lack of insurance to mitigate those costs), and language and cultural barriers.

To ensure that all North Carolinians have the opportunity and ability to access quality oral health care, hundreds of thousands of people are going to need additional resources. These resources include, but are not limited to, Spanish language forms and bilingual staff, financial assistance, and more dental offices in rural communities.

NCOHC is collaborating with oral health professionals and community leaders across the state to plan and implement equitable solutions to our oral health crisis. If you want to learn more, be sure to check out NCOHC’s resources on Oral Health Equity. Join our email list to receive regular updates on NCOHC’s work and learn how you can get involved.

Be sure to tune in next week for our breakdown of the systemic barriers to oral health and how we can reach the equitable landscape depicted in the third panel of the comic strip below!

Equality vs Equity vs Justice Comic
Image courtesy of the City for All Women Initiative’s guide, “Advancing Equity and Inclusion.”