Service Delivery ModelUpgrading access and delivery of dental services to a special needs

group

Identifying the NeedO One dentist and dental nurse currently providing

dental care for a homeless population of 2,366 O HSE funded initiativeO Traditionally emergency service and

comprehensive treatment provided – Bottle NeckO Average of 750 appointments per year since

2003O Eligiblity for treatment depends on Medical Card

entitlementO Opportunity to upgrade service delivery to reach

more patients and remove the barriers to accessing care

Barriers to accessing careO Lack of available

informationO Location and timing of

servicesO Fear and intimidation

from dental staffO Financial difficulties or

no medical cardO The administrative

systems and the attitudes of service providers.

O THESE NEED TO BE ADDRESSED

Exceptional/High RiskO Clause activated - November 2011 O Medical Card holders eligible for full

range of dental treatment by virtue of their dental vulnerablility (see Appendix 1)

O PRSI scheme (social insurance) abolished 2009 and Medical Card limited to 2 emergency fillings per year in 2010

O Private GDPs are willing to accept referrals from Homeless services where they weren’t previously

Determining PrioritiesO The priority is to increase access for

homeless people to dental services

O Provide them with information on services available

O Establish rapport with patients to alleviate fear

O Provide assistance with medical card application

O Determine their dental need and provide relief of pain as priority initially.

O Provide support for General dentists who are willing to accept the patient referrals, by means of telephone and visits where necessary.

Identifying Objectives (SMART)

O S- Assess 30 per week for level of need, medical card status/eligibility and Triage and refer to suitable GDP/MQ emergency

O M- Record number of patients attending screening sessions and number of patients attending for Emergency relief of pain. Follow up with dental practices with phone call to measure level of attendance for consultation and follow up treatment.

Identifying Objectives (SMART)

O A- Success of screening, triage, referrals satisfaction of patients and GDPs

O R- Target Number of patients per week is 30 Target number of GDPs in the referral pathway 8. Is this sustainable? Necessary? Other factors preventing us reaching target

O T- Time frame of 6 months for a pilot with a 3 month reflection period

Programme ImplementationO Identified 8 units to be targeted for screening

chosen due to existing referral pathway with dental services and previous presence in these units

O Units differed in type of homeless service day center/residential setting/methadone treatment center

O Age profile and level of level of dependency differed in units

Meet Staff in Units Unit date ResponseO Orchid House 19/01/12

PositiveO Sundial House 19/01/12

PositiveO Focus George’s Hill 20/01/12

PositiveO Focus Coffee Shop 24/01/12

PositiveO Castle St. 26/01/12

PositiveO Trinity Court Pearse 24/01/12

PositiveO Merchant’s Quay 31/01/12

NegativeO City Clinic Amiens 07/02/12

Positive

Meeting SummaryO Outline proposal to use premises

for dental screenings for clients of the facility

O Explain that clients should be assisted by units to apply for medical cards via the ‘Fast Track’ Online service

O Clients will be listened to and examined to ascertain their need and matched with a suitable dentist

O Emergency dental care available in MQ 2 days per week without medical card

O Any Questions from staff answered

General Dental PractitionersO Contacted GDPs in the Dublin

city center areas by phone for willingness to accept referrals from Homeless services

O All clients eligible for treatment under Medical Card Exceptional/High Risk clause

O Eight accepted proposalO Create positive relationship

with reception staff/dental nurse and the senior dental nurse for Homeless services to ensure efficient referral pathway

Clinical Dental Technician

O A Clinical Dental Technician or CDT is a registered Dental Care Professional who is trained and qualified to provide a range of denture services directly to patients.

O Eight in Rep. Of Irl one of whom is close by in Dublin

O Referrals made for all dentures in same manner as to GDPs with Medical Card subject to approval

Dental ScreeningsO January 2012 to June 2012 – 18 screenings carried out O Assess Med card status & provide support for medical card

applicationO Examine using DenlightO Discuss patient needs and wants O Discuss suitable venue for treatmentO Explain Exceptional/High Risk clause subject to approvalO Get Patient details to contact later that day

Triage Form

Eligibility Form for GDP records

AdministrationO Back at base check Med Card status &

PPSN (personal public service number)O Make best match with GDP & clientO Make referral calls if not already done

during screeningO call client with details of referralO copy screening form & eligibility form

and post to GDPO Follow up phone call 1 week later to GDP

and client

Mid Point ReflectionO At 3 month point in projectO GDPs – 10 more requested to join the referral

pathwayO Units – positive response asking for sister

satellite units to be screened in the futureO Clients – suitable clients were referred by

staff of units to GDPs with advice from Homeless unit

O Information – Medical card eligibility, access to dental services more readily available to clients in their own units

O Emergency treatment in MQ still heavily subscribed

Table 1: 6 month evaluation Number of clients screened and

referredNumber Screened in Units

216

Number Referred To GDPs

180

Number Referred to CDT 12

Number Treated for Emergency Care MQ following screening

36

Number taken on for comprehensive care by Homeless Service

8

Number Attending MQ as per usual for Emergency Tx

69

Total number of sessions (am/pm)

48

Making sense of the figures Table 1

O Number of clinical sessions Jan-June 2012 Screening + MQ emergency = 48

O Total number of clients seen- 216 Screenings + 69 Emergency MQ = 285

O Av. Number of clients per session = 6

O Session is AM or PM

Table 2:Number of procedures carried out2008*,2007,2006,2005

* week 9 2008 to week9 2009

Appointments

946

Emergencies

301

Fillings

769

Extractions

207

Dentures

198

Root Canal

10

739 329 479 214 40 4

917 332 577 324 45 45

755 309 465 427 81 15

Making sense of the figures Table 2

O Total number appointments annually- 839 Av.

O 52 weeks in year minus 9 weeks Annual Leave/Bank hols/Sick leave etc = 43 weeks

O 7 sessions per week x 43 = 301 sessionsO Av. number of clients seen per session

- 2.8O Many of these clients were repeat visits. In

2008 there were 279 individuals treated over 946 appointments. Compare this with 289 in 6 months pilot 2012

Figure 1: Number of Clients catered to per session in 2012 compared with previous years

2005 2006 2007 2008 20120

1

2

3

4

5

6

No.

Clien

ts

Figure 2:Referral outcomes with GDPs & CDT & Homeless Dental

0

20

40

60 47

8 6

36

122 2

814

29 12

57

0 2 3

Tx Complete Tx IncompleteDNA Don't Know

Supported Medical Card Application

Successful ApplicationNo Application

DiscussionO The initial findings suggest more clients are

being cared forO Administration - Labour intensiveO Evident by the fact that there is a high

number of clients in the ‘Don’t know’ category of the follow up data

O Of the clients referred to GDPs 44% are non contactable for follow up

O It is unrealistic to think that the service could move forward without the support of dedicated staff, at least a specialist dental nurse and ideally a specialist dental team

DiscussionO Attendance at the Emergency

drop-in in MQ is still heavily subscribed lending support to the belief that the chaotic nature of homelessness does not marry well with an appointment service

O What the client ‘wants’ and what they are capable of is often at odds

O The most successful referral pathway is to a GDP who operates a ‘walk in’ service in Dublin 1

O Sometimes the city needs a whole warehouse dedicated only to Bananas

ReferencesO Slide 1http

://www.homelessagency.ie/Facts/Homeless-Figures.aspx ‘Measuring Homelessness’ accessed 12/01/12

O Slide 3 Holohan T (1997), “Health Status, Health Service Utilisation and Barriers to Health Service Utilisation among the Adult Homeless Population of Dublin”, Dublin, Eastern Health BoardO Slide 14 http://www.cdtai.ie/ Clinical Dental TechnicianSlide 23HSE Special Needs Dental Report 2007, 2008