Practicing under Public Health Supervision in Iowa

Have you ever wondered what dental hygiene practice options are available that would offer you a professional challenge, open doors to new opportunities, provide the unique satisfaction that accompanies being able to provide services to people unable to obtain them? Then you may want to investigate practice as an Iowa public health hygienist as a new career option, as a part-time vocation, or even on an occasional or volunteer basis.

Practicing under public heath supervision in collaboration with a dentist means that you could provides services for patients in a school, Head Start program, federally qualified health center, public health dental van, free clinic, non-profit community health center, nursing facility or a state, local or public health program without a dentist having to see the patients before treatment. You would practice according to protocols and standing orders contained in a written agreement with the dentist. You could provide services under the auspices of the school, clinic or other setting where you practice and could be employed by or contract directly with the setting. However you would maintain contact and communication with the dentist providing public health supervision. A dentist would provide future examinations of your patients according to the specification of the agreement.

Public Health Supervision: Is it Right for You?

Educ

atio

nal &

Exp

erie

ntia

l Req

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men

ts

• An active Iowa license

• Minimum of 3 years clinical experience

• No special educational requirements

• Must collect data on services provided

• Must have procedure for maintaining records

Pra

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vaila

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to a

PH

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• Schools • Head Start • FQHCs • Public health

Dental vans • CHCs • Nursing facilities • Free clinics • State/local/

federal public health programs

Serv

ices

a P

HSH

can

Pro

vide

• Assessments • Screenings • Data collection • Educational,

diagnostic, preventive and therapeutic services defined in the rules

• May NOT provide local anesthesia or nitrous oxide.

Requirements for Practice as a Public Health Supervision Hygienist (PHSH)

Settings Requirements Services

Some services required to maintain Public Health Status:

Practice as Public Health Supervision Hygienist– What Else Do I Need to Know?

Statutes & Rules Applicable Forms State Dental Practice Act Iowa Code 153 Iowa Code 147 Iowa Code 272C http://www.state.ia.us/dentalboard/ Dental Board Rules http://www.state.ia.us/dentalboard/

Public Health Supervision PHS Application http://www.idph.state.ia.us/hpcdp/ohds.asp PHS Reporting Form http://www.idph.state.ia.us/hpcdp/ohds.asp Iowa Dental Board http://www.state.ia.us/dentalboard/

• General supervision is required for a hygienist providing direct services.

• Iowa’s Title V agency requires that a local dentist be identified as the supervising dentist and the hygienist or community health agency have a written agreement with a dentist providing general supervision.

• A dentist is required to see a patient prior to a hygienist providing

sealants, prophylaxis and radiograph services under general supervision.

• Detailed rules about dental hygiene supervision may be found on the Iowa Dental Board website link: http://www.state.ia.us/dentalboard/

IF YOU DO NOT HAVE A PHS AGREEMENT

THREE PUBLIC HEALTH SUPERVISION (PHS) HYGIENISTS SHARE THEIR EXPERIENCES

NANCY practiced in a community health center that conducted an oral health education and screening program in the school system that it served. Data gathered from the screening found the number of sealants present on children’s teeth to be quite low. So when funding became available to develop a school sealant program at the same time that Healthy Iowa 2000 set a goal to increase the number of children with sealants, the clinic developed a sealant program using dentists in the community to do the assessment exams required under general supervision. However, Nancy explains that as the program grew it was difficult to always arrange to have a dentist for the exams.

Fortunately for the success of the program, at the petition of the Iowa Dental Hygienists’ Association (IDHA), the Iowa Dental Board had approved a rule change to allow for public health supervision. After the rule was changed the clinic developed public health supervision collaborative contracts with the dental clinic director. This allowed for the sealant program to expand without having to have a community dentist available for the sealant assessments because dental hygienists could assess under public health supervision.

The initial rule stipulated that the child could not be seen again until they had been seen by a dentist for an exam. The IDHA petitioned the board successfully to allow the collaborating dentist and dental hygienist to determine when a child had to be seen by a dentist before the dental hygienist could provide services again. This was great for sealant re-checks because there was worry about when the child had last seen a dentist.

MARY was also associated with a safety net dental clinic, working in school based settings. She began practicing under public health supervision in 2004, practicing in WIC clinics, Head Starts and community programs for teens through a Title V agency’s I-SmileTM program – and also on her own doing volunteer work in the community at a high school and working on a program for nursing facilities.

MARY’s program had challenges similar to Nancy’s program before practice under public health supervision was available. “The children would leave the classroom for exams and again when I would provide my services. If a child was not in the classroom that day, he would miss out. When this opportunity came along, we could save our dentist volunteers for doing the restorative services while we did the determination of appropriate preventive dental services (sealants, prophylaxis or fluoride). This also made the students only leave the classrooms once for the preventive services and increased our ability to treat the children who were absent the day the dentist was there for exams.”

NANCY says there are no typical days because several programs go on at the

same time. “I participated in an Education and Screening program that provided class room oral health education and dental screenings to determine if a child needed sealants and or dental care. Referrals were made and sealant permissions were sent home with the children. We had a sealant program that targeted 2nd and 3rd graders that needed sealants. We used portable dental equipment in the schools to provide sealants for the children that participated in the program. We also had a fluoride varnish program for Head Start programs and low income preschool programs. These programs were all run at the same time with 3 dental hygienists sharing responsibilities for all programs. Every day was different.”

MARY agrees that “there never is a typical day --which makes this position the most interesting. In WIC clinics I typically meet with Mom and child, discussing a lot of anticipatory guidance, especially in regarding to feeding practices. I apply fluoride varnish as needed. Head Starts are a complete contrast because I see the child only, sometimes educating the children in a group and then applying fluoride varnish right in the classroom.”

NANCY advises other hygienists interested in doing a sealant program to do a

thorough assessment of the population that you want to serve before starting. She says: “The more data you have that a need exists, the easier it will be get support for the program. I would also suggest checking with Federally Qualified Health Centers (FQHC) and Title V agencies in your community as they are required to provide dental services. The dentists in these clinics (FQHC) may be willing to be a part of a public health supervision contract.”

MARY urges colleagues to be creative because there are many different settings

possible within the guidelines of the PHS requirements.. She points out that there are many opportunities for partnerships with nursing facilities, local Head Starts and community programs that will allow you to work as much or as little as you would want. Her final word on PHS practice? “The rewards are endless and worth it!”

JOYCE, currently the I-Smile coordinator for 5 counties, shares some scenes of Public health supervision hygienists in practice.

“During the 2010 calendar year, 63 RDH with PHSA provided 54,000 dental screenings, 32,000 fluoride varnish applications and 20,000 dental sealants.” JOYCE began working with the I-Smile Program with New Opportunities., a TitleV agency in Carroll, IA (See http://www.iowadha.com/i-smile.html for more information about the I-Smile program and employment opportunities). As part of the public health position, she needed a Public Health Supervision Agreement to provide services in the public health sector.

Joyce’s agency provides numerous public health services and their program provides dental screenings and fluoride varnish applications in WIC programs, Head Start, ECI, local schools (providing dental screenings for kindergartners and ninth graders). Joyce’s projects include advocating for continued water fluoridation and presenting a PowerPoint to medical offices about children’s dental needs and fluoride varnish applications.

At WIC clinics, she provides dental screenings, periodontal assessment, prophylaxes (when appropriate), oral health education, fluoride varnish applications and dental referrals. With the public health supervision agreement, she can provide these services without a dentist being present to provide an examination.

If you are self-employed you will be responsible for paying your own social security and federal and state income taxes directly to the government. To learn more about income reporting requirements, visit: http://www.irs.gov/businesses/small/index.html

For more business information check out the Small Business Association’s Website. http://www.sba.gov/category/navigation-structure/starting-managing-business/starting-business/

Business Considerations

• It is very unlikely that you will be employed by your public health supervision dentist. In fact, the school, clinic or other setting where you practice is likely to contract with you, rather than hire you as an employee. So even though you are still practicing under a form of supervision, for business purposes you may be self-employed.

• Some PHS/RDH are employed by Community Health Centers (CHC), Federally Qualified Health Centers (FQHC) or local public health program (I-Smile).

Why you need professional liability insurance! Insurance coverage held by the employer is written to protect the employer and patients served by the employer. Individual employees have limited protection and limited access to the legal defense services provided to the policy holder. If you are self-employed you need individual protection for yourself and your business even more so. Professional liability insurance coverage is generally restricted to matters relating to patient care - it will not cover loss or damage to equipment, general negligence issues or other matters. ADHA offers great information on professional liability and other types of insurance for self-employed dental hygienists, as well as equipment replacement insurance at: https://www.personal-plans.com/adha/welcome.do

Insurance & Liability

In order to file an electronic claim to a third party payer, whether private insurance or Medicaid, you need your own National Provider Identifier (NPI). An NPI is a 10 digit number, assigned for free by the federal government, that serves as a permanent identifier of you as a healthcare provider, even if you move or are relicensed in a different profession. Iowa dental hygienists at the present time are not directly reimbursed by either Medicaid or private insurance. However, even if you do not bill third parties directly, you can apply for the free NPI anyway because it may facilitate billing submitted by a health department or other entity for services that you provided. For more information about the NPI and how to obtain one, please visit the NPPES website or https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart or contact NPPES directly by phone at (800) 465-3203.

Payment: NPI

Additional State Resources

For a state wide listing of CEU’s visit the IDHA’s continuing education page: www.iowadha.com/edu.html Contact information for experienced PHSH practitioners who are willing to mentor newcomers: American Association of Public Health Dentistry: www.aaphd.org Bureau of Oral and Health Delivery Systems (OHDS): http://www.idph.state.ia.us/hpcdp/ohds.asp Iowa Dental Hygienists’ Association 1490 Kent Avenue Kanawha, IA 50477 Phone: 641-762-8217 Email: www.abbas3@comm1net.net Website: www.iowadha.com

Mary Kelly: marykellyrdh@msn.com Joyce Miller: joyce602@mchsi.com

ADHA Resources

•The Working column in Access magazine highlights dental hygienists who have pursued a variety of career paths: http://www.adha.org/publications/working/working.htm • ADHA’s Standards for Clinical Dental Hygiene Practice:

http://www.adha.org/downloads/adha_standards08.pdf •ADHA’s Public Health Listserv is a forum to exchange information about careers and practice in public health: http://adha.org/lists/index.htmlhttp://adha.org/lists/index.html •ADHA on facebook:

http://www.facebook.com/youradha • ADHA on Linkedin:

http://www.linkedin.com/groups?gid=2875805&trk=hb_side_g