Summary of AAPD “Filling the Gaps” Task Force Visit to
AMERICAN ACADEMY OF
PEDIATRIC DENTISTRY
“Filling Gaps” Task Force Visit to
North Carolina
JUNE 11-13, 2001
In 1999, the American Academy of Pediatric Dentistry (AAPD) was awarded a four-year Children’s Health Insurance Program Partnership Grant by the HRSA Bureau of Maternal and Child Health. The purpose of the grant is to identify and develop “best practice” protocols and training materials designed to increase the access of preschool children to dental care and to improve their dental health. A Task Force of AAPD members was formed to carry out the mission of this grant, entitled “Filling Gaps: Integrating Service Systems to Improve Children’s Access to Oral Health Care.” In June, this Task Force conducted a site visit to North Carolina (NC) to examine aspects of two separate, but related programs developed by different groups in NC to improve oral health and access to oral health services for young children by engaging non-dental health care providers and community workers:
• Smart Smiles Dental Project: a regional program initiated by a consortium of rural western NC communities in partnership with the Oral Health Section, NC Division of Public Health and
• Into the Mouths of Babes Project: a state-wide demonstration program initiated by the NC Division of Medical Assistance (the state’s Medicaid agency) with financial support from the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) of the U.S. Department of Health and Human Services.
During the site visit, the AAPD team met with a variety of program officials and staff, health care providers, community-based workers, representatives of professional organizations, researchers and parents to identify what elements of these programs appear to be working effectively, perceived challenges, and suggestions for improving the programs. The site visit team also had an opportunity to observe services being delivered under both programs (on a limited basis due to logistical constraints) and an Into the Mouths of Babes training session for physicians and members of their office staff.
Both the Smart Smiles and Into the Mouths of Babes (IMB) programs appear to have similar general goals:
• To increase awareness of the importance and determinants of oral health in young children within communities and among non-dental health care providers, particularly those who have periodic contacts with children up to 3 years of age;
• To promote greater involvement of non-dental health care providers (e.g., pediatricians, family physicians, nurses) and community-based workers (e.g., WIC personnel) in oral health assessments, parental counseling, anticipatory guidance, and fluoride varnish (FV) applications;
• To promote more collaborative approaches by community-based health workers, dentists and medical care providers to the delivery of recommended oral health services.
Despite these similar goals and the fact that Into the Mouths of Babes grew out of early work in the Smart Smiles project, the two programs have several distinguishing and have developed along slightly different lines. Brief synopses of both programs and information gained during the course of the site visit follow.
Smart Smiles
Smart Smiles is a program created through a partnership of the Oral Health Section, NC Division of Public Health (OHS), the University of North Carolina at Chapel Hill, the Ruth and Billy Graham Children’s Health Center, the NC Partnership for Children (Smart Start), and a coalition of county-based non-profit organizations operating in nine western NC counties. The nine counties were selected because statewide screening data indicated that they had the highest rates of tooth decay for kindergarten enrollees. Smart Smiles is linked to Smart Start, a Governor’s initiative focused on educational readiness through day care, child care and “family enhancement” programs. The program is supported by a grant from the Appalachian Regional Commission. Additional funding is being sought from the National Institutes of Health to assess the program’s effectiveness in reducing tooth decay at age 3 and age 5 as well as changes in dental treatment patterns and costs.
Smart Smiles participation (eligibility) criteria include:
• Children from 9 months to 36 months of age,
• Families whose household income is < 200% of the federal poverty level (FPL),
• Children with older siblings who have experienced tooth decay,
• Children who are nutritionally compromised.
Services provided by the Smart Smiles project include:
• Dental screenings (with a basic focus on the presence or absence of dental caries/tooth decay),
• Oral health and anticipatory guidance counseling for parents, and
• Fluoride varnish applications.
Children enrolled in Smart Smiles may be seen for up to six appointments while in the program, with inter-appointment intervals as low as every four months.
Oral Health Section administrative officials and staff had, and continue to have, integral involvement in the development and implementation of the Smart Smiles program. Initially, OHS staff developed training programs and related materials for non-dental providers. Additionally, OHS dental hygienists work within targeted communities on an ongoing basis to furnish training for non-dental providers, post-training program implementation support, and care coordination (e.g., identifying children in need of services or follow-up care). The program was funded by a federal grant from the Appalachian Regional Commission in October 1998 and began delivering services in September 1999.
Major Perceived Strengths / “What’s Working”:
• Local coordination and community outreach efforts
• Enrolling and providing services to high-risk children at an early age (6-10 months)
• Educating parents about children’s oral health and prevention beginning at an early age
• Raising awareness about the importance of oral health and the extent of the problem of access to oral health care for young children within involved communities and among non-dental health care providers
• Reimbursement is serving as an incentive to engage providers to provide services.
Major Perceived Challenges:
• Improving parental compliance
• Getting parents to bring children back for services on a regular basis
• Reducing broken appointments
• Sustainability
• Improved Medicaid reimbursement for oral health services
• Continuation of resources for community-based case management by OHS dental hygienists and EPSDT/Health Check workers
• Maintaining the integrity of the Smart Smiles program (i.e., avoiding program “dilution”)
• Getting dental and medical groups to work together at the community level to integrate services and develop adequate referral systems
• Getting non-dental health care providers to adopt and “institutionalize” oral health services into their routine practices if post-training follow-up support is not provided.
Into the Mouths of Babes
Into the Mouths of Babes is a statewide program created by the NC Division of Medical Assistance, the agency that operates the state’s Medicaid program, with support from a demonstration project funded by the Centers for Medicare and Medicaid Services. The pilot phase of Into the Mouths of Babes was launched in December 1999. The Division of Medical Assistance expanded the program statewide in February 2001.
Into the Mouths of Babes participation (eligibility) criteria include:
• Children from birth to three years of age,
• Children who are eligible for NC Medicaid, which for categorically needy children in NC generally means being in a family whose household income does not exceed 185% of the FPL prior to one year of age or 133% of the FPL once children reach age one.
Administrative elements of the Into the Mouths of Babes program include:
• A one-hour training session that includes presentations on billing procedures (provided by EDS, NC’s Medicaid claims vendor) and early childhood caries and fluoride varnish application (provided by a dental hygienist employed by the NC Pediatrics Society, the state’s chapter of the American Academy of Pediatrics, and the NC Academy of Family Physicians,
• Reimbursement for a bundled set of procedures including an oral health assessment, oral health counseling, and a fluoride varnish application. Reimbursement for these bundled procedures is $43 for children seen on an initial visit and $35 at subsequent visits.
Major Perceived Strengths / “What’s Working”:
• Providing substantial access to oral health services, including fluoride varnish applications, at an early age and on multiple occasions at relatively short intervals according to a flexible schedule for a high-risk population that generally has not received services heretofore
• Reimbursement levels are viewed as “good” by participating pediatricians
• Provides a new focus on oral health in pediatrics practices and fits a prevention framework embraced by primary care physicians and members of their staffs
• Greater awareness of oral health problems in young children and enthusiasm on the part of the medical community and parents to do something about it
• Support from physicians’ professional organizations.
Major Perceived Challenges:
• Children who lose eligibility for the program because of their age (i.e. when they turn three) or because of changes in income eligibility limits once children reach age one (i.e., income eligibility criterion changes from 185% of FPL up to age one to 133% of FPL thereafter)
• Developing an integrated system of services across medical and dental providers to deliver the full range of oral health services that children in low-income families need
• Sustainability could be an issue once federal funds that support provider training have expired or as a consequence of state budget cuts
• Health care professions “turf” issues
• Response (or lack of response) of the dental profession, education programs, and the dental care delivery system in NC (especially general dentists) to dental workforce and competency issues.
Additional Observations
1. Smart Smiles services provided by Health Department personnel – Site visitors had an opportunity to observe services (oral health assessments, parental counseling and fluoride varnish applications) being provided to Smart Smiles enrollees by a staff nurse at the Rutherford County Health Department. The nurse was enthusiastic in her discussions with parents and adept at positioning infants to facilitate oral health assessments. The parental counseling component focused primarily on how to clean children’s teeth, with little emphasis on the importance of frequent fluoride exposures in reducing or preventing tooth decay. This issue was discussed during a subsequent group session with health department and community-based staff and OHS officials. OHS officials acknowledged the need for periodic review of Smart Smiles training materials to ensure that they continue to reflect contemporary consensus on effective ways to reduce dental caries (tooth decay). There is also a need for periodic training updates for providers participating in Smart Smiles.
2. Into the Mouths of Babes training session for physicians and office staff – Site visitors were allowed to sit in on an actual training session for physicians and members of their office staffs held at the Bowman Gray-Wake Forest University Medical Center. The first part of the session was conducted by a representative of EDS, the NC Medicaid claims processing vendor, and focused on physician office billing for allowable Into the Mouths of Babes procedures. The second half of the presentation provided a brief overview of oral health problems in young low-income children and summarized what the program is trying to accomplish. The primary focus of this segment was on literature supporting the use of fluoride varnish (often at a very detailed level, perhaps too detailed for the target audience) and group instruction on how to perform oral health assessments and FV applications.
Although the information presented was generally sound, site visitors noted that:
• There was very little explanation of dental caries (tooth decay) as a disease process,
• Clinical slides showing different stages of caries formation were included, but attendees received no “hands on” experience in conducting oral health assessments,
• The technique for applying FV was demonstrated on a model, but “hands on” experience was not provided, (It must be noted, however, that current issues related to dental hygiene scope of practice and supervision in North Carolina have complicated efforts to include “hands on” demonstrations by the hygienist that coordinates this training.), and
• The bulk of the time was spent discussing fluoride varnish, thereby reinforcing the notion (heard frequently at various site visit sites) that this is a “fluoride varnish program” (i.e., the oral health assessment, counseling, and referral aspects are not emphasized to the degree that FV applications are).
Site visitors also expressed concern about these statements made during the course of the presentation for the reasons noted:
• “prevention is the solution” – a position that ignores the acute dental treatment needs of children covered by Medicaid and EPSDT program requirements to provide treatment for conditions identified on screenings,
• various “opinions” downplaying certain aspects of recommended FV application protocols that seemed to have been aimed at overcoming physicians’ concerns about potential patient/parental acceptance issues, but which could alter the effectiveness of the FV – e.g., “parents can brush it off if they don’t like the looks of it” and “the printed material says to use a soft diet for the day of the application, but I don’t think food will scrape it off,”
• “it is unacceptable to use APF gel in small children” because of the amount that would be swallowed – a statement that distorts the risk of APF use, especially if recommended protocols are followed.
Related Issues
The major thrust of the two NC programs that were the focus of this site visit is to involve non-dental health care providers (physicians and allied primary health care workers) in oral health assessments, parental counseling, anticipatory guidance and fluoride varnish applications. Additionally, the programs seek to develop more effective community-based approaches to improving oral health for high-risk infants and young children. Discussions and observations during the site visit gave rise to the following related policy questions and perspectives.
1. Non-dental health care provider competencies and training: What services can physicians and allied primary care health workers be expected to provide effectively (competently) with respect to oral health care for infants and young children, and what level of training do they need to effectively perform those services?
Recent studies by Lewis et al.,[1] suggest that pediatricians often lack basic knowledge about children’s oral health and common oral conditions. Recent and as yet unpublished work in North Carolina by Pierce et al.,[2] indicates that after “special training” in infant oral health, pediatricians and nurse practitioners achieved a sufficient level of accuracy when screening for dental caries (tooth decay) at the person-level; however their accuracy at the tooth-level was inadequate. The special training in this case consisted of an additional hour of instruction in dental screening and infant oral health beyond the standard IMB training session and post-training support in the form of an on-site pediatric dental resident who worked with medical staff members over a period of six weeks. Evidence concerning the competencies or performance of individuals who participate in the Into the Mouths of Babes program is not available; nor are any studies planned to address this important program policy question. Feedback obtained from the pediatricians who participated in the Pierce et al., study and nurses involved in the Smart Smiles program indicated that these two groups of non-dental health care providers consider such post-training support to be extremely beneficial, and perhaps even critical to achieving adequate performance.
Post-training support, which has been readily provided through Smart Smiles by the OHS dental hygienists and has been less available in Into the Mouths of Babes due to staffing limitations, also is seen as a key function to promote adoption and sustained implementation of oral health services by physician practices, especially by family practitioners. Several individuals who met with the site visit team expressed concern about physicians in their communities who had participated in the IMB training sessions, but had not initiated the delivery of oral health services in their practices. Some speculated that not training the entire medical office staff simultaneously (i.e., relying on those who attended training to train others in the office) may delay or impede implementation of service delivery.
2. Reimbursement: What should physicians be paid for oral health assessment (i.e., should an oral health assessment be considered part of an EPSDT general physical assessment or should providers of such general assessments be paid extra for conducting oral health assessments? If so, should reimbursement for an oral health assessment be comparable to what a dentist is reimbursed for providing an examination? If not, what level is reasonable?)? Should physicians and/or medical personnel be paid for oral health counseling when such services typically are not reimbursed when provided by dental personnel?
Into the Mouths of Babes oral health services provided by physicians and allied primary care personnel include: an oral health assessment (screening), parental counseling, and fluoride varnish application. Reimbursement for this bundled set of services was set at $43 for an initial encounter and $35 for subsequent periodic visits. Program officials indicated that these reimbursement levels were based on existing NC Medicaid reimbursement levels for “comparable services” provided by dentists or dental hygienists. However the studies cited above regarding physicians’ limited knowledge and skills with respect to oral health assessments (even after more extensive training than is provided in the IMB project) and the lack of any formal assessment of knowledge or skills following the single IMB training session raise questions as to whether this policy actually represents parity. Oral assessments/screenings aid in the identification of high-risk or affected children who require further evaluation, treatment planning and/or treatment, but are not equivalent to or a substitute for dental examinations. Some, in fact, argue that oral assessments/screenings should be considered an integral component of the general physical assessment procedures required by EPSDT guidelines. Similarly, oral health counseling generally is not a reimbursable service in Medicaid dental programs (although many would argue that it is a justifiable procedure for high-risk children).
3. Responsibilities for referrals: What are the responsibilities of physicians and community-based workers and, in turn, the Medicaid program once a child has been identified on screening as being in need of follow-up dental care – be that a more thorough examination, treatment planning and/or treatment services?
In light of the early onset and recurring nature of dental diseases in children and the chronic pervasive nature of dental access problems for Medicaid-eligible children, it is essential that a wide range of health care providers be involved in monitoring children’s oral health status on a regular basis. Yet, in spite of their importance, screening activities or programs that lack effective linkages to dental care providers capable of providing needed diagnostic, disease management and treatment services are of little value and largely act as a drain on scarce resources. “Referral” means more than advising someone – in this case a Medicaid-eligible child or family – that they need follow-up care. Within the health professions and health care delivery systems, “referral” means arranging for a patient to see another provider deemed capable of providing necessary follow-up services. In referring a patient, the responsibility for that aspect of the patient’s subsequent care is shared or transferred to the provider to whom the referral is made, with appropriate feedback to the referring provider.
State Medicaid programs are ultimately responsible for assuring that direct referrals for necessary post-screening follow-up dental diagnostic and treatment services are made, and that children identified as needing such services get to dentists’ offices or other suitable treatment facilities in a timely manner. Accordingly, if initial (e.g., screening) providers are not able to arrange for referrals directly, they have an obligation to inform the responsible program administrators or intermediaries (e.g., health plans) who then have the responsibility to see that necessary referrals are arranged and that care is initiated in a timely manner.
4. NC dental workforce: The programs that were the focus of this site visit in NC arose out of the desire to improve oral health and address acute dental access problems for young, high-risk children. North Carolina has one of the lowest dentist-to-population ratios in the entire United States. Efforts are being made by state officials to reduce barriers to dentists moving to NC and to recruit dentists to practice in dental service shortage areas. However, many individuals who met with the site visit team expressed doubt that these efforts would prove sufficient to provide adequate access to dental services unless additional steps are taken to address broader dental workforce issues.
Summary
Dental disease (primarily tooth decay) and access to oral health services are substantial problems for young children from low-income families in North Carolina. State officials and local community activists have created two programs (Smart Smiles and Into the Mouths of Babes) that seek to engage non-dental healthcare personnel – pediatricians, family physicians, and allied primary care providers – and community organizations in this problem. Officials report that hundreds of providers have been trained and over 7,500 children have received services, with Medicaid reimbursements totaling nearly $340,000 (as of 4/30/01). It must be noted that these Medicaid funds come from the medical portion of the Medicaid budget and do not represent a diversion of funds from the ongoing Medicaid dental program. Discussions and observations during the recent AAPD “Filling Gaps” site visit indicate considerable enthusiasm for these programs on the part of participating medical practices, health departments and community workers. However, there seems to be little evidence of integration of medical and dental services within communities thus far. Furthermore, evidence regarding the effectiveness and cost-effectiveness of these programs will not be available for several years and is likely to be difficult to interpret. In the meantime, additional steps to promote optimum program performance, enhance collaboration among dental and primary care health professionals and community workers to improve children’s oral health, and address dental workforce issues in NC appear to be warranted. Such efforts continue to receive considerable attention from the stakeholders involved in these two programs.
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[1] Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the oral health of children: a national study. Pediatrics 2000;106:xxx-xxx.
[2] Pierce KM, Rozier RG, Vann WF Jr. Accuracy of PPCPs’ screening and referral for early childhood caries. Study conducted by researchers at the University of North Carolina at Chapel Hill.
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FILLING GAPS
A Grant of AAPD
211 E. Chicago Ave., Suite 700
Chicago, IL 60611-2663
Phone: 312-337-2169
Fax: 312-337-6929
Project Coordinator:
Libby Mullin
3703 Legation St. NW
Washington DC 20015
Phone: 202-686-7386
libbymullin@
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