Advancing Oral Health of Underserved Populations through ...

Advancing Oral Health of Underserved Populations through Innovative Oral Health Care Delivery Models:

Registered Dental Hygienists in Alternative Practice

Beth MertzNovember 4, 2008Dental Public Health Seminar Series

2

Overview

• Study background, methods and funding• History of Independent Hygiene• Legislation and Regulations• RDHAPs and Access to Care

– The people

– The business of practice

– The practice environment

– Patients and systems

• Frameworks for analyses• Conclusions & Implications

3

Project Funding

This research was supported by funds from the California Program on Access to Care (CPAC), California Policy Research Center, University of California, Grant Number FN007A. The views and opinions expressed do not necessarily represent those of The Regents of the University of California, CPAC, its advisory board, or any State or County executive agency represented thereon.

Prior data collection efforts were supported by:• California Dental Association• HRSA, BHPr, Center for Health Workforce Information and

Analysis• NIH, NIDCR, Center to Address Disparities in Children’s Oral

Health at UCSF• California Dental Hygiene Association

4

Study Background

• Access to dental care is a problem for many people in society for a variety of reasons

• Health disparities have been widely documented

– Recent deaths from dental infections

– Most prevalent childhood disease

• Connection to overall health and well-being

• Existing strategies concentrate on dentist supply, diversity and distribution (i.e. expansion of safety net) or on public health interventions (expansion of water fluoridation, sealant programs)

• The RDHAP, originally intended as an independent hygienist, ultimately emerged as a strategy to address unmet need for preventive services in underserved communities

– My research question started with a desire to know how the practice had been evolving since implementation

5

Aims of Study

• To profile the existing RDHAP workforce in contrast to the general RDH workforce with the purpose of better understanding the practice settings, practice types, populations served, and clinical service provision that are unique to RDHAPs.

• To explore the practice realities of RDHAPs as they enter their communities and develop new models of dental hygiene care outside the traditional dental office.

• Review and summarize legislation and policies pertaining to RDHAPs and develop recommendations for policy makers on improving RDHAPs’ current and future contributions to improving access to preventive dental care for underserved populations in California.

6

Methodology

• Mixed method study– Literature review

– Legislative / regulatory review

– Quantitative analysis of 2005-2006 Survey of Dental Hygiene

– Qualitative interviews with 12 RDHAPs and 5 organizational representatives (CDA, CDHA, COMDA, UOP, WLAC)

• Conducted and coded using grounded theory methodology

7

History of Independent Dental Hygiene

Who are these RDHAPs and how did they get here?– 1900s – Resistance to assistance

– 1950s / Post-WWII – Desperation for assistance

– 1970s – Feminism blooms in the female workforce

– 1980s & 1990s – Free markets and access to care

– 2000 and beyond – Health disparities change the political climate…

Nothing radical or new about the idea of independent hygiene, has been in development for 50+ years

8

Current State of Affairs

Rationale for Change

Experiments

Boundaries

Evaluations

What isn’t working and for whom?

What are side

effects?

Access to care

Health Inequalities

Practice efficiency

A linear development process…?

RDHAP

Safety

Legislation

Lawsuits

Professional Pressure

Populations

Sites

Process

Outcomes

9

Or not…?

10

Legislative/Regulatory Background

• What is “new” is the implementation of the idea• Twenty year process in California (1980 – 2003)

– Two Health Manpower Pilot Projects (HMPP)

– Two Lawsuits – First won by hygiene, second lost on a technicality, hence second HMPP

– Final compromise to enactment restricted independent practice to underserved areas

– Five years “legal” before “reality” due to lack of an education program

– Ongoing issues include: • Prescription requirement, referral agreement, limitations on scope,

Denti-cal payment, self-regulation (enacted in CA 2008 – first State in the US to have this)

11

YesDentalBoard

Standing Orders from Employer/Supervisor

DentalHygiene

Yes-GeneralPublic Health Hygienists

NoMedicalBoardCommittee

Referral Agreementwith MD to practice

DEM Scope

NoDirect Entry Midwife

NursingBoard

NursingBoard

MedicalBoardCommittee

NursingBoard

NursingBoard

DentalBoardCommittee*

RegulatoryBoard

NoReferral Agreement With DDS for licensure

Dental Hygiene

(-)

NoRDHAP

YesEmploymentRN ScopeNoRegistered Nurse

YesStanding OrdersRN ScopeNoPublic HealthNurse

YesDelegation ofServices Agreement

PA Yes - DirectPhysician Assistant

YesStandardizedProcedure Requirements

Expandedfrom RN

CollaborationCertified Nurse Midwife

YesStandardizedProcedure Requirements

Expandedfrom RN

CollaborationNurse Practitioner

InstitutionalBased Agreement

Agreement TypeDuties / Scope

SupervisionRequirement

*changing to self-regulation as bureau under DCA

12

RDHAP Distinctive Workforce Characteristics (2005)

• As a group, compared to RDH’s they:

– Are more educated,

– Are more diverse,

– Are more active in the labor market,

– Work longer hours per week with more administrative time,

– Are more likely to consult with other health care providers,

– Are more likely to see special needs patients,

– Provide a broader range of services within their scope,

– Are more likely to work in non-traditional settings, and

– Express a commitment to professional growth, access to care and service to underserved populations and communities.

13

Practice Status

Practice Status: All California Hygienists by RDH License Category

16.7%8.4% 8.0%

83.3%91.6% 92.0%

0%

20%

40%

60%

80%

100%

RDH RDHAP RDHEF

Not Active

Active

14

Primary Practice Type: California Hygienists by RDH License Category

98.5%91.7%

1.5%8.3%

0%

20%

40%

60%

80%

100%

120%

RDH RDHAP

Clinical

Non-Clinical

Practice Type

15

RDHAP/EF Practice Status

Active Dental Hygienists in CaliforniaPercent with Advance License Practicing in the

Capacity of an Advanced Practitioner

73.0% 71.4%

0%

20%

40%

60%

80%

100%

RDHAP RDHEF

PercentPracticingas AP/EF

16

RDHAP Practice Settings

RDHAP Practice Settings

15.07%

43.84%

31.51%

13.69% 13.69%

43.84%

17.80%

0%

10%

20%

30%

40%

50%

Schoo

ls

Resid

entia

l Fac

ility

Privat

e Pra

ctice

DHPSA

Insti

tutio

n

Homebo

und

Other

17

Age Distribution

Mean Age 46.9 for RDHAP, 44.7 for RDH – no significant difference

Active Hygienists in California:Age Distribution

0%

10%

20%

30%

40%

50%

18-3

0

31-4

0

41-5

0

51-6

565

+

%RDHAP

%RDH

18

Active Hygiene Workforce in California: Demographic Profile

26.6%34.7%Foreign Language*

8.5%21.2%URM*

8.1%19.0%Hispanic*

97.5%96.3%Female

2.5%3.7%Male

RDHRDHAP

*Statistically Significant Differences – Chi-Square Tests

19

Active Hygiene Workforce in California:Education and Licensure

Active Dental Hygienists in CaliforniaHighest Level of Education Attained

(in any field)

52%43%

5%

30%

56%

14%

0%10%20%30%40%50%60%

Cer

tificat

e/Ass

ociate

Bacca

laur

eate

Mas

ters

/Doc

tora

lPerc

en

t o

f R

DH

s

RDH

RDHAP

No difference in average year first licensed (1987) or percent educated in California (78%)

20

RDHs Only (no EF or AP responses included)

RDH Intention to Pursue AP or EF

Active Dental Hygienists in CaliforniaIntention to Pursure Additional AP/EF Licensure

15.9

%

15.1

%

5.1%

5.9%

59.2

%

14.9

%

13.4

%

3.5% 9.

0%

58.1

%

0%

20%

40%

60%

80%

100%

Not Likely Somew hatUnlikely

Somew hatLikely

Very Likely Not surew hat this is

RDHAP

RDHEF

21

Workload

Comparison of Average Days Worked per Week RDH & RDHAP

3.783.37

0

1

2

3

4

5

RDHAP RDH

Avg

. D

ays

per

Wee

k

RDHAP RDH

22

Workload

Mean Hours Worked in Each Activity Per WeekActive Dental Hygienists in California

23.3

0.80.1 0.

40.

0 0.21.

40.

0 1.3

30.1

24.8

2.2 1.9

22.9

05

101520253035

Pa

tien

t C

are

Ad

min

istr

atio

n

Pu

blic

He

alth

Act

iviti

es

Te

ach

ing

Re

sea

rch

Oth

er

Pro

fess

ion

al

To

tal

RDH

RDHAP

23

RDH Labor Market

100%Clinically Active Dental Hygienists in CaliforniaDifficulties Encountered in Finding a Position

(Respondents can check all that apply)8.

7%

8.7% 16

.3%

18.5

%

22.8

%

18.5

%

9.9%

9.8%

47.8

%

0%

10%

20%

30%

40%

50%

60%

No Diff

iculty

No Full

-Tim

e

No Part-

Time

No Spec

ific D

ay

Inad

equat

e Sala

ry

Inad

equat

e Ben

efits

Work

Env

ironm

ent

Trave

l Dist

ance

Oth

erPe

rce

nt

Re

po

rtin

g D

iffi

cu

lty

RDHAP

RDH

24

Patient Characteristics

Patient Distribution of Clinically Active Dental Hygienists in California (2005-2006)

1.37

% 8.44

% 15.0

1%

67.3

4%

2.43

%

0.9% 6.

9%

2.4%

0.5%

11.1

%

32.4

%

2.9%5.

81%

67.3

%

18.0

%

5.6%

46.7

%

6.4%

0%

20%

40%

60%

80%

100%

Africa

n-Am

erica

n

Amer

ican

India

n

Asian-

Pacific

Islan

der

Hispan

ic/La

tino

Whi

te

Other

RDH RDHAP CA Population

25



0.1%4.2%

12.4%

61.8%

21.3%

61.2%

21.3%

12.3%5.0%

0.6%

0%

20%

40%

60%

80%

Children Age0-1

Children Age2-5

Children Age6-17

Adults Age18-64

Adults Age65+

RDH

RDHAP

26



16.8%

2.9%

2.6%

1.5%

25.8%

4.7%

5.6%

2.6%

0% 5% 10% 15% 20% 25% 30%

MedicallyCompromised

DevelopmentallyDisabled

Mentally Ill

BehavioralChallenge

RDH

RDHAP

27

0.2201(1.28-1.62)1.45(1.60-3.56)2.58Behavior Management

0.0148(2.33-2.79)2.56(2.51-8.77)5.64Mentally Ill

0.0608(2.73-3.08)2.91(2.58-6.80)4.69Developmentally Disabled

0.0397(15.99-17.64)16.81(19.83-31.80)25.81Medically Compromised

0.9839(20.61-21.9221.27(17.43-25.25)21.3465+

0.8831(61.00-62.60)61.80(56.73-65.63)61.1818-64

0.9779(11.89-12.82)12.35(10.23-14.34)12.296-17

0.5007(3.97-4.40)4.18(3.64-6.29)4.962-5

0.0690(0.08-0.17)0.12(-0.03-1.19)0.580-1

Age

0.9642(2.14-2.72)2.43(1.54-3.18)2.36Other

0.9860(66.38-68.30)67.34(62.45-72.05)67.25White

0.3528(14.41-15.62)15.01(13.81-22.14)17.98Hispanic/Latino

0.5333(7.98-8.89)8.44(5.07-8.79)6.93Asian/Pacific Islander

0.6072(1.19-1.55)1.37(0.52-1.23)0.88American Indian

0.8906(5.53-6.10)5.81(4.10-7.11)5.6African-American

Race

0.1250(1.74-2.11)1.93(1.81-5.08)3.44Difficulty with Language

0.7481(8.29-8.44)8.36(8.15-8.82)8.49Patients per Day

CIMeanCIMeanPatient Population

PRDH (10855)RDHAP (n=100)

28

Number of Practice Sites

9.76%19.32%3 Sites

30.12%39.77%2 Sites

60.12%40.91%1 Site

RDHRDHAPNumber of Practice Sites

29

Practice Sites - RDH

Clinically Active RDHs in CaliforniaWork Settings

0.06%

0.79%

0.23%

0.00%

0.03%

0.43%

1.00%

2.55%97.45%

Private Office

Hospital

Indian Health

Military/VA

Prison

CommunityClinic

School

Teaching/Research/Other

Sum of Practice Sites, RDHs may have up to 3 practices

30

Practice Sites - RDHAP

Clinically Active RDHAPs in CaliforniaWork Settings

0.63%

4.40%

0.00%

7.55%

0.00%

1.89%

10.06%

24.53%75.47%

Private Office

Hospital

Indian Health

Military/VA

Prison

CommunityClinic

School

Teaching/Research/Other

Sum of Practice Sites, RDHAPs may have up to 3 practices

31

RDH Benefits

Comparison of Benefits Received Across Practice Sites

5.9%

7.3%

2.8%

35.4%

26.7%

48.8%

29.0%

52.4%

20.4%

64.8%

5.4%

35.9%

25.0%

45.7%

25.0%

45.7%

12.0%

51.1%

9.8%

10.9%

0% 20% 40% 60% 80%

Paid Liability/Malpractice

Disability Insurance

Paid Professional Dues

Retirement/Pension Plan

Medical Insurance

Paid Vacation

Production Bonus

CE

Paid Sick Leave

Dental Care/Coverage

Percent of Practice Sites Offering Benefit

RDHAP More likely to have

RDH More Likely to have

32

Wage Information

Clinically Active RDHs in CaliforniaAverage Hourly Wage by Region

$50

.91

$47

.28

$45

.15

$45

.10

$44

.84

$44

.77

$43

.92

$43

.76

$42

.02

$40

.12

$39

.19

$45

.56

$30

$35

$40

$45

$50

$55

Bay A

rea

Centra

l Coa

st

S.Bor

der

Centra

l Sier

ra

S. Coa

st (L

A)

N Cal

Wes

t

Great

er S

ac

N Cal

East

Inlan

d Em

pN S

ac

SJ Val

ley

State

wide

Ho

url

y W

ag

e

33

Comparative Wages

Comparison of RDH and RDHAP Wages Across Practices(*All but Practice 1 are statistically significant differences)

$45

.63

$45

.52

$45

.06

$45

.28

$46

.47

$48

.22 $

52.1

9

$50

.73

$30

$35

$40

$45

$50

$55

Practice 1 Practice 2 Practice 3 Average Wage

Ho

url

y W

ag

e

34

Health Care Professional Consultations

Distribution of Reported Consultations Outside Primary Dental Care Team

52.6%

4.5% 5.

1% 6.0%

2.1% 3.

7%

28.2%

46.7%

14.1%

14.1% 18

.5%

8.7% 12

.0%26

.1%

47.4% 57

.6%

0%10%20%30%40%50%60%

Dental

Specia

list

Physic

ian*

Physic

ian A

ssist

ant*

Nurse P

racti

tioner

*

Registe

red

Nurse

*

Nutrition

ist*

Other

*

None

RDH

RDHAP

•Statistically significant differences

35

Scope of Work

0.1051 (0.12-0.14)13%(0.16-0.31)23%Cosmetic

0.4306 (0.36-0.38)37%(0.36-0.46)41%Surgical

0.0716 (0.08-0.09)8%(0.10-0.21)16%Restorative

0.6580 (0.92-0.93)92%(0.92-0.96)94%Therapeutic

0.2145 (0.81-0.83)82%(0.83-0.90)87%Preventive

0.1346 (0.68-0.69)68%(0.70-0.77)73%Diagnostic

WeightedCIMeanCIMeanScope

PRDH (11,083)RDHAP (n=109)

*No Statistical Differences

36

Job Satisfaction

* Significant Difference – Sorted by Degree of Difference

Comparison of Importance of Elements of Job Satisfaction

4.19

4.62

4.40 4.

54

4.53

4.85

4.05

4.77

4.07

4.28

4.07

4.47 4.

59

4.38

4.16

3.55

4.16

3.95

4.14 4.

25

4.70

3.91

4.65

3.98

4.19

4.03

4.44

4.60

4.51

4.12

3

4

5

Opp fo

r Adv

ance

men

t*

Profe

ssion

al Gro

wth*

Variet

y of R

espo

nsibilit

y*

Auton

omy*

Inte

llectu

al Stim

ulatio

n

Respect

for A

bilitie

s

Benef

its

Accom

plish

ment

Emoti

onal D

eman

ds

Type

of Pra

ctice

Physic

al Dem

ands

Flexibilit

y

Worki

ng w

ith P

eople

Inco

me

Current

Job

Satisfac

tion

Ave

rag

e S

core

RDHAP

RDH

37

Professional Membership

Comparison of Dental Hygienists'Membership in Professional Association

77.78% 79.59% 78.79%

34.72% 36.06%32.89%

0%

20%

40%

60%

80%

100%

ADHA CDHA Member of CDHA orADHA

RDHAP

RDH

38

Professional Opinion Questions

• Hygienists were asked if they personally, as a dental hygienist, agreed or disagreed with personally doing or wanting to do specific activities.

• For exact wording of each question, please refer to the survey instrument.

39

39.1%69.5%64.8%40.1%34.5%93.9%49.8%28.1%31.9%30.0%66.5%58.0%56.7%67.3%51.9%53.7%57.6%

95.9%91.8%94.9%70.4%59.0%87.4%95.8%88.4%88.7%77.1%94.9%16.5%94.7%95.8%69.5%81.3%79.4%

Would like Self Employment without SupervisionWould like General Supervision Only

Would like Prescriptive AuthorityWould like to do Restorative Procedures

Is Not Practicing to Full ExtentThinks Current Environment Good Fit

Would like to Work Outside Dental OfficeWould like to be Directly Reimbursed

Desires to Work with Disadvantaged PatientsDesires Work with Underserved Community

Thinks Improving Access is ImportantThinks Current Regulatory Structure is OK

Would Agree to License Fee Increase for Self-RegulationWould like to Interact with non-Dental Health Providers

Would Have Liked Loan Repayment OptionWould be part of Volunteer Emergency Registry

Is Interested in Job in DH Administration or Education

Percent AgreeingPercent AgreeingRDHAP vs. RDH

RDHRDHAP

Professional Opinions

40

Percent of Active Hygienists Currently Working in Non-Traditional Settings

8.2%

74.8%

16.7%

91.8%

25.2%

83.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

RDH RDHAP RDHEF

No

Yes

Non-Traditional Settings

41

Practice in Unsupervised Public Health ProgramComparison of RDH, RDHAP & RDHEF's in California

98.6%

75.0%

94.4%

25.0%

5.6%1.4%

0%

25%

50%

75%

100%

RDH RDHAP RDHEF

Yes

No


42

Practice in Non-Traditional SettingsComparison of RDH, RDHAP & RDHEF's in California

90.2%

33.3%

83.3%

9.8%

66.7%

16.7%

0%

25%

50%

75%

100%

RDH RDHAP RDHEF

Yes

No


43

Type of Non-Traditional SettingsActive Hygienists in California

(n=1089)

0% 10% 20% 30% 40%

Hospital

Home Health Agency

Local Public Health Clinic

Community Centers

Nursing Home/Assisted Living

Community/Migrant Clinic

Schools

Fed/State/Tribal Institution

Homebound Residence

Other

RDHEF

RDHAP

RDH


44

Factors in Decision to work in a Non-traditional Setting

0%

20%

40%

60%

80%

100%

Desire

for C

halle

nge*

Job

Flexibi

lity*

Bette

r Hour

s/Sch

edul

e*

Profe

ssio

nal S

tand

ing*

Bette

r Sala

ry*

Inte

ract

ion w

ith H

C Pro

fes.

..

Job

Secur

ity*

Comm

unity

Servic

e*

Perso

nal S

atisf

actio

n

Bette

r Ben

efits

Oth

er

Only

job

availa

ble

Mov

ing to

new

com

mun

ity

RDH

RDHAP

*Statistically Significant Differences


45*Statistically Significant Differences

Educational Preparation Helpful in Preparing to Work in a Non-Traditional Setting

0%

20%

40%

60%

Financia

l Man

agem

ent*

Inte

rdisc

iplina

ry T

eam

s*

Progr

am P

lanni

ng a

nd E

val*

Perso

nnel

Man

agem

ent

Oth

er

Patien

t Ass

essm

ent

Med

ical E

mer

genc

y Tra

ining

Adapt

atio

n to

NTS

Patho

-Phy

siolo

gy

No Addit

iona

l Tra

ining

Behav

ior M

odific

ation

/ Com

pl

Health

Edu

catio

n

Cultu

ral C

ompe

tenc

y*

Comm

unicat

ion/In

terp

erso

nal*

RDH

RDHAP


46

Ease of Referral to DDS from Non-traditional Practice Site

15.94

% 20.5

5%24

.13%

34.5

1%

4.88%

11.2

7%14

.08%

16.9

0%

53.5

2%

4.23

%

0%

10%

20%

30%

40%

50%

60%

Easy Somew hatEasy

Somew hatDif f icult

Diff icult NotApplicable

RDH

RDHAP


47

Workforce Summary

Size and Scope of the Workforce• The RDHAP workforce is demographically similar to

the RDH workforce, perhaps slightly older, more racially and linguistically diverse, and on average more educated.

• Between 5-15% of the current RDH workforce (est.13,500) may be interested in pursuing expanded or alternative practice, or in working in non-traditional settings.

• RDHAPs report more difficulty finding employment than RDHs.

48

Workforce Summary

Practice Issues• Reported hourly wages are higher but benefits

offered are on average fewer. • Job satisfaction is determined by different criteria for

each group, however overall is similar between RDHs and RDHAPs.

• RDHAPs attitudes toward practice environment are vastly different than RDHs on every aspect of scope, responsibility, independence, regulation and variety of settings and populations served.

49

Workforce Summary

Access to Care• The patient population of RDHAPs is not significantly

different by race or age, however is different by mental and medical disability status.

• RDHAPs are more likely to consult with other health care providers in the care of their patients, and likely to have a more difficult time referring to a dentist when needed.

• The practice settings of RDHAPs is very diverse and non-traditional, especially focusing on homebound and facility bound patients.

50

Access to Care

• As an Outcome• Measured by utilization rates

• Indicators are decay rates, age, race, SES, etc.

• As a Process• No static measures of a process

• Examined though qualitative interviews focused on understanding experience of people in the system

51

The Process of Expanding Access

• Who does it?• What do they have to do?• What is the environment in which they do their

work and how does this impact their doing it?• Who do they do it for?

52

What motivates an RDH to become an AP?

Pushes– Dissatisfaction with private practice

– Poor relationship with dental employers

– Perception of poor quality in dental offices

– Frustration with not being able to see patients with special needs in private practice

Pulls– Mission driven – desire to serve community, freedom to develop

own business

– Independence - pioneering, initiative, resilient

– Professional rewards - autonomy, choice, agency, teamwork within other health systems

53

“I think it's people who have always worked with developmentally disabled, always worked with the elderly population, always worked in the schools. All of us had some extended involvement with the community outside of just working for three days, five days a week in a regular dental practice. We all were involved in a different capacity, and I think that's what this program attracts is people who really, sincerely want to help. It's not a money thing.”

“And I think you really need to be a dynamic dental hygienist, a go-getter, seasoned, able to handle any situation. I really enjoy it. I'm having some frustrating getting into some facilities but I'm determined to get everything going. “

“So many of the patients that I was seeing to route into care – there was no place to route them. And it was a frustration for me. I even went to work at a community clinic so I could see – I took a job for a lot less money in a clinic so that I could actually provide good preventive hygiene care to these patients because I saw the need. “

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The Business of Practice

• Business plans – Develop in education program, many go on for more education in this

• Clinicians, case managers, multiple roles and sites

• Developing payment structures – What can and will I charge?

– Who will I charge?• Start up money and equipment

– Mobile equipment runs $25K, need small business loan, and must develop charting systems, administrative systems

• Building the business– Strategies vary by setting and community

– Diversification helps mitigate risks

– Creating awareness of services for consumers as well as health care systems

• Overcoming Resistance / Building Relationships

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I can only speak for myself – I'm out there in a non-traditional setting in the schools looking at a population to move into doing dentistry. But then as soon as I look into doing dentistry in a borrowed office or on an adult, I put myself right back into the private practice mental box. So I know there's a whole population out there because those are the people I deal with through the school program, but when I start thinking about a private practice and the business reality of making a fee and doing the business and paying the bills then I want to make some money too and I've just excluded the very population that I was hoping to take care of because I stuck myself back in the box.

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One of the reasons why I didn't take this course earlier several years ago, because I was afraid of being shut down. But the reason I'm taking the course now is because a dentist that I work for right now has five different facilities that he goes to and he needs a hygienist. And he doesn't want to do any of the cleanings. So he talked to me and he said, “Why don't you go and take the course and get your AP? I want to bring you in. I'm going to do the dentistry part, do the exams, do the restorations, and I want you to help me out. We'll be in partnership and you do the cleaning.”

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• Who does it?• What do they have to do?• What is the environment in which they do

their work and how does this impact their doing it?

• Who do they do it for?

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Structural Environment of Practice

• Laws/Regulations– Allow practice but also limit it

– Title 22/OBRA – vague construct creates confusion

• Care systems– RN, LTC homes, Schools, Clinics, etc

• Payment systems– Denti-cal, self pay, insurance companies

• Competitive (anti?) practices of dentists– Lawsuits, exclusion from institutions, slanderous marketing &

fear mongering, betrayal of trust, exclusion of suppliers or collaborators.. The precedent was set early and goes on…

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“It's a fear, because we could be shut down any day. And we're seeing this on a daily basis and new dentists are coming into the facilities or wherever we are and they're threatening the facilities and saying – and you've heard this already – “If you let that RDHAP come in I will go away and you will not be able to fill your state requirement.” So I think a lot of us – I have my reasons. I'm diversified and I like being diversified – there's safety in being diversified, security in that. But I think a lot of APs are not willing to walk away from that safety home of a dental office and employment to risk their whole entire – everything they've built for their twenty years in dentistry to have some guy come in and put them out of business after they've already invested $25,000 in equipment.”

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I think that comes down to, again, the fight – who wants to fight the fight. If we market ourselves then someone is going to come out of the woodwork and come up against us. And I know a lot of hygienist APs have said this to me: “I'm working way down here on the radar screen for the purpose of that. I've already run into trouble. I don't want to initiate it again.” And it's really unfortunate because there is such a thing as fair trade, you know? And it is unfortunate that we feel like we can't go out there and toot our horns and say, “Look, we're providing a wonderful service.” I think a lot of us that are starting out would probably like to do a little more marketing and maybe go after some high-paying patients but I think people are afraid of the backlash. Are they going to start calling OSHA on us? You know, any excuse to squelch the situation.

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RDHAP Patients & Settings

• Homebound and institutionalized elderly• Developmentally disabled / residential care homes• Denti-Cal Patients • Rural children and families• Migrant farm workers• Pregnant women and their children / WIC• Community clinic clients• Public health clients• State institutionalized adults

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Core Value - Focus on the Patient

• Desire to serve patients in a patient-centered model

• Developing mechanisms for reaching out to patients in their communities and institutions

• Improving ways of managing care for patients with special needs

• Achieving improvements in health!

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Patient Centered Care

“I'm serving the very young and the very old. I would say five of the children I saw yesterday were under the age of 3 and I just get right down on the floor with them and I polish their teeth while they're sitting on dad's lap on the floor and make it a game and then I gradually transition them into getting into the dental chair, and by the end of the appointment they've allowed me to scale their teeth, they've allowed me to clean out little areas. If I need to put in little temporary medicated restorations I can do that. So then people will say, "Gosh, we've took our son to three different dentist and he wouldn't open his mouth. It's amazing, you got x-rays, you cleaned his teeth."

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Reaching out to Patients

“I want to clean those teeth, the guys I have seen for ten years at my Special Olympics, my group homes – I know their names and they know who I am. They run to me to get dental screening at the Special Olympics. I know some of them have behavioral issues. I want to go to those homes and clean those people's teeth.”

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Improving Patient Health

I think what we have accomplished with our fluoride varnish program, and we're talking a rural area with limited access to care. I see children where literally people live up there like squatters in a lot of these areas. It's just really sad. I see kids who are just filthy yet the decay is arresting itself. And I just last week in two days saw like 137 children. I saw seven children that I actually saw that had caries that they had three years ago that had not been treated. After treating them none of them had pain. The tissue was healthy in those sites because the caries had been arrested. It's just phenomenal. What I have seen from the program that we've done is just -- I honestly think if this kind of thing were adopted statewide it would just save the taxpayers hundreds and thousands of dollars in restorative dentistry; it really would.

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Going to the patients

“We are there to provide services and to make these people have a sense of dignity and care because they are basically forgotten. Nobody wants to take care of their dental needs. Some of these people have been going to the dentist for years and then they get into a situation where they’re in a nursing home and all of that is gone.”

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New and Different?

• Commitment to patient centered process • Resilience - take a hit (or three) and get back to it• Pioneering – Delivering care where none existed

before• Transformative potential?

– Building new relationships with communities and practitioners

– Unearthing system failures and inequalities previously hidden from view

• What concepts can help us think about this?– Paradigm Shifts

– Social Entrepreneurs

– Innovations in Care Delivery

– Institutional Changes

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Changing the paradigm?

• A Paradigm is a philosophical and theoretical framework of a scientific school or discipline within which theories, laws, and generalizations and the experiments performed in support of them are formulated

-Webster’s dictionary

• How are paradigms created and how do they shift?

– Slowly and incrementally

– Drastically and revolutionary

• Arguments for and against RDHAP as a new paradigm

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This is not a paradigm shift….

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Oral Health Entrepreneurship

• A social entrepreneur is someone who recognizes a social problem and uses entrepreneurial principles to organize, create, and manage a venture to make social change. Whereas a business entrepreneur typically measures performance in profit and return, a social entrepreneur assesses success in terms of the impact he has on society.– Are they measuring success by how many underserved patients

they can bring in to the system and care for?

• Measurements on health outcomes are slim… bottom line always matters for survival

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Innovations in Care Delivery

• Invention is the first occurrence of the idea, innovation is the first attempt to carry the idea into practice

• Some definitions of innovation…– The act of introducing something new

– A new idea, method, or device

– Change that creates a new dimension of performance

– The process of making improvements by introducing something new

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Introducing Something New

• New provider – RDHAP as both an innovation and an innovator– They are the embodied implementation of the new provider type.

However, they themselves are not new

– As an independent provider, they are developing and implementing new systems to expand access to care

– Professional framework still strong, self-imposed limitations on ways to think about work, lack of critical mass for policy change

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Creating Value

• Value for whom?– Customer (AP in community) or employer (RDH in dental office)

• Do RDHAP’s make society better off?– Measuring benefits from innovations in care delivery

• Much literature focuses on organizational gains

• Community and access outcomes are harder to track and report, external to the system

– Innovations have destructive potential too…

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Institutional Change ProcessCan we see all of “dentistry” as an institution? Or just organized

dentistry?

• Denial: A self-protective state to avoid being overwhelmed• Resistance: Mourning and distress; passive-aggressive

resistance• Acceptance: Inevitability of impending change is recognized• Bargaining: Attempts to piecemeal or sequester the new plan• Exploration: Future-focused thinking about how to integrate the

new plan into the mainstream of the institution• Commitment: Proactive efforts to make the new plan work

effectively• Comfort: The plan is not longer “new” but is perceived as routine

and “our way”.

Adapted from: Hendricson, W and Cohen, P (2001) Oral Health Care in the 21st

Century, Academic Medicine, 76(12), p1199

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Conclusions

• The combination of professional independence and a required focus on underserved populations is powerful in both motivating and structuring RDHAP practice.

• The diversity of strategies employed by RDHAPs in developing their practices has opened up multiple pathways to creating and improving access to dental care.

• The independence of RDHAPs as providers allows them the freedom and flexibility to reach out to patients in new and creative ways.

• New collaborative practice models, with dental, medical, and other caregivers will be needed to transform these innovations into comprehensive care delivery for patients.

• Meeting the challenge of transforming the system and reconnecting oral health with overall health will require a professional commitment to ensuring a high quality workforce, a regulatory environment flexible enough to allow for innovation, and a care delivery system that is consumer-responsive and affordable.

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Policy Recommendations1. The State should grant licensure for RDHAPs based on

qualifications, and should eliminate prescription requirements for dental hygiene services provided by RDHAPs.

Patients should have their choice of a dental hygiene care provider, and the public should not need a prescription to receive basic preventive care.

• The State should appoint an independent committee to review, and make recommendations to the legislature on “scope of practice” matters.

This practice allows for a less politicized review of efforts to increase the capacity of the health workforce, and it is operating successfully in many other states and countries. In addition, the State should encourage competency based health care practice models which are flexible and responsive to community health care needs. The State should also restructure professional boards in a way that allows each profession to regulate its own members.

• The State should encourage reciprocity across state lines for all new dental workforce models.

New models include the Advanced Dental Hygiene Practitioner model developed in Minnesota, and the Dental Health Aide Therapist model developed in Alaska. New models for dental and hygiene education can help ensure a high quality workforce.

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Policy Recommendations

1. Denti-Cal should maintain reimbursement rates at levels that sustain dental hygiene services, and should expand reimbursement to RDHAPs for non-clinical services, such as case management, health education, and prevention services.

RDHAPs should be able to bill for their services as a corporation.

• Denti-Cal and Medi-Cal should be integrated to develop a comprehensive data infrastructure.

Such an infrastructure would be capable of tracking health care expenditures, health care utilization, health diagnoses, and health status. Integration could lead to new research for quality of care improvements, and shed light on health care savings attributable to preventive dental care (i.e. examining health cost savings for diabetes treatment resulting from preventive dental care treatment). Policy makers might consider incentives for the oral health community to develop better quality of care measures, such as developing health outcomes measurements.

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Policy Recommendations

• The State should revise regulations within long-term care and skilled nursing facilities to include more specific oral health standards, and allow more flexibility to meet these standards though collaborative dental service models.

RDHAPs should be eligible to fulfill the Title 22 provider requirement for a dental program in nursing homes. RDHAPs are well suited, both in skill set and practice model, to be on-site primary dental care practitioners, providing preventive and educational services in these settings.

2. The State should continue to encourage doctors and dentists to work with underserved populations.

For RDHAPs, working with underserved populations is a practice requirement. A set of similar mandates for other dental practitioners may go a long way towards improving access to the restorative and surgical treatments needed by many underserved individuals.

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Implications

• Lessons learned from the process of RDHAP development and implementation are important to success of new models across the country

– Must have support from broader institutional systems which are complex and contradictory

– Focus on patients needs may get new efforts further in developing a model than a focus on the redesign of a professional hierarchy

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Don’t forget to vote!

Beth MertzProgram Director

Center for the Health ProfessionsUniversity of California, San Francisco

3333 California Street, Suite 410San Francisco, CA 94118

Phone: 415/502-7934Fax: 415/476-4113

[email protected] Web: http://futurehealth.ucsf.edu

http://futurehealth.ucsf.edu/

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