Your Oral Health Program: Strategies for Success · Your Oral Health Program: Strategies for Success BCBS Foundation Training December 1 & 2, 2017 . Preparation ... /year with 1100

Your Oral Health Program: Strategies for Success

BCBS Foundation Training December 1 & 2, 2017

Preparation • Download Today’s Learning Materials:

• Go to www.dentaquestinstitute.org

• Click on Learn and then Resource Library

• Click on the “BCBS NC Training 2017 ” folder

• Download the presentation, activities and handouts

• Go to survey monkey and fill out the pre-training evaluation: https://www.surveymonkey.com/r/BCBS17Pre

http://www.dentaquestinstitute.org/

https://www.surveymonkey.com/r/BCBS17Pre

https://www.surveymonkey.com/r/BCBS17Pre

Welcome & Introductions

Who We Are • Safety Net Solutions (SNS) is a program of the

DentaQuest Institute (DQI) • DQI is part of the DentaQuest Enterprise whose mission is to

improve the oral health of all

• DQI is an improvement organization focused on creating an effective and efficient oral health care delivery system

• SNS provides practice management technical assistance consulting to safety net dental programs helping them achieve their goals in areas such as increased access, strengthened financial viability, and improved quality outcomes

44 states + District of Columbia; Close to 500 programs

Purpose of Today’s Training

Share knowledge, best practices and meaningful resources related to safety net dental program management in the areas of access to care, financial sustainability and quality outcomes

Learning Objectives • Upon completion of this training, participants will:

• Understand the practical, credible benchmark metrics for safety net dental programs

• Determine the capacity of their dental programs and the impact that working under or over capacity has on a safety net program and its patients

• Develop realistic and achievable goals in the areas of access, finance, outcomes, and quality

• Collect and organize key practice management data necessary to evaluate their dental program

• Utilize tools to track, measure, and evaluate performance of the dental programs

• Develop effective policies and procedures for managing broken appointments and emergencies

• Design a strategic scheduling template to maximize access and dental program financial viability

• Determine the right dental staffing mix for your dental program • Promote staff accountability and improve morale

Today’s Presenters • Dr. Bob Russell, Dental Director & Bureau Chief, Oral & Health

Delivery Systems Bureau, Division of Health Promotion and Chronic Disease Prevention

• Danielle Apostolon, Senior Program Manager, Safety Net Solutions

• Dori Bingham, Program Manager, Safety Net Solutions

• Dr. William Riley, Professor, School for the Science of Health Care Delivery; Director, National Safety Net Advancement Center

• Caroline Darcy, Project Manager, Safety Net Solutions

Tomorrow’s Presenters

• Ann Cadoret, RDH, MSDH, Project Manager, Safety

Net Solutions

• Dori Bingham, Program Manager, Safety Net

Solutions

• Danielle Apostolon, Senior Program Manager, Safety

Net Solutions

• Caroline Darcy, Project Manager, Safety Net

Solutions

Today’s Agenda

Welcome & Introductions

Dental Program Redesign: Laying the Groundwork

Planning for Dental Program Success Part 1 – The Mission: Access, Capacity and Productivity

Lunch

Today’s Agenda, Cont. Developing Productivity Goals – Demo of SNS Tools

Planning for Dental Program Success Part 2 – the Margin: Understanding Finance in Dental

Developing Financial Goals – Demo of SNS Tools

Break

Payment and Care Delivery Reform in the Healthcare Safety Net

Q&A/Small Group Discussion

Closing/Wrap-Up

Dinner

Reception & Recreation

Dental Program Redesign

Laying the Groundwork for Redesign

Received his dental training at Loyola University of Chicago School of Dentistry and public health training at the University of Michigan School of Public Health

Published a dental training manual for FQHCs

Developed a statewide care coordination and promotions campaign in preparing dental hygienists to increase access to oral health care and prevention for Medicaid and uninsured children

Bob Russell, DDS, MPH, CPM Dental Director & Bureau Chief Oral & Health Delivery Systems Bureau, Division of Health Promotion and Chronic Disease Prevention / Iowa Department of Public Health

Full member of ASTDD as a state dental director

Has served on the Board of Directors for the Association of State and Territorial Dental Directors, the National Network for Oral Health Access, the Delta Dental of Iowa Foundation, the HHS Advisory Committee on Training in Primary Care Medicine and Dentistry

Newly minted Fellow of the American College of Dentists

• Understand: “What success looks like or should look like in an FQHC dental program.”

• Recognize the critical domains related to a safety net dental program

• Learn the critical differences between Medical and Dental

• Understand the practical, credible benchmark metrics for each domain

• Understand the link between Capacity and Visits/Access

• Learn what data to collect

• Be able to define the priorities for dental success

• Understand the Quality and Governance big picture

• Learn about the dental part of the OSV

• Understand FTCA better

Learning Outcomes

2017 Centers of Excellence

Access Before SNS After SNS Increase/

Decrease

Average %

Increase/

Decrease

Number of Visits 42,795 48,944 6,149 20%

Unduplicated Patients 14,919 22,564 7,645 53%

Number of Procedures 59,039 128,667 69,628 111%

Procedures per Visit 1.5 2.4 .8 77%

Broken Appointment

Rate 34% 20% 14% points 34%

Average of 6 dental programs

2017 Centers of Excellence Results

Access Before SNS After SNS Increase/

Decrease

Average %

Increase/

Decrease

Number of Visits 42,795 48,944 6,149 20%

Unduplicated Patients 14,919 22,564 7,645 53%

Number of Procedures 59,039 128,667 69,628 111%

Procedures per Visit 1.5 2.4 .8 77%

Broken Appointment

Rate 34% 20% 14% points 34%


2017 Centers of Excellence Results

2017 Centers of Excellence Results, cont.

Finance Before SNS After SNS Increase/

Decrease

Average %

Increase/

Decrease

Gross Charges $6,793,673 $11,978,135 $5,184,462 133%

Net Revenue $6,582,391 $9,474,896 $2,892,505 60%

Bottom Line $41,486 $2,381,006 $2,339,520 222%

# of sites operating in

the red 3 0


2017 Centers of Excellence Results, cont.

Outcomes Before SNS After SNS Increase/

Decrease

Average %

Increase/

Decrease

Treatment Plan

Completion Rate 4% 53% 49% points

# of Sites Tracking

Completed Treatment

Plans 2 6

Number of Sealants 2,210 4,367 2,157 203%


Where Do We Start?

Access 1 Finance 2

Outcomes 3 Quality 4

Governance 5

Five Domains to Understand and Own

How Medical and Dental Differ

Another Essential to Know and Understand

Medical

20% of clinic volume

80% of visits varied

80% of visits = longer (45)

80% of billing varied

80% of visits treatment

80 % of RVU different

0% of governance is designed around dental

EDR silo

Not familiar with dental model

Lack of confidence

80% of clinic volume

80% of visits similar

80% of visits = shorter (15)

80% of billing similar

80% of visits diagnostic

80% of RVU similar

100% of governance is designed around medical

EMR silo

Familiar with medical model

Confident leadership

Dental

Our Program Goals are

My Goals are

My Role is

My Responsibilities are

Your Goals, Roles, and Responsibilities are

We need to get this done by

And… by the way:

THIS IS HOW WE ARE EVALUATED

Clarity

1300-1600 encounters/year/FTE hygienist

2500-3200 encounters/year/FTE dentist

2700 encounters /year with 1100 patient base/DMD

1 patients/50 min.

9 patients/day/hygienist

1.7 patients/hour or 13.6 patients/day/dentist

2.5 ADA coded services

/treatment visit

Access Benchmarks

15% No-Show rate

<6% Emergency Rate

33% Comp TX. Plan is Fair #New Patients =

#Completed Treatments

2.5 Visit/Year/Patient

Access Benchmarks cont.

Finance Benchmarks

Gross Charges =

>$400K-$500K per dentist per year

$183 average cost per encounter (UDS 2015)

330 = 12.4% Allocation Average

Gross Charges =

>$150K-$200K per RDH per year

2016 UDS National Data Averages

• 2,614 visits/year/FTE DDS for a panel of 1,100 patients

• 2,200 visits/year/FTE RDH

• 2.55 visits/year/unduplicated dental patient

• Each dentist treated a panel of 1,100 patients

• Unduplicated dental patients make up 21.9% of all health center unduplicated patients

• 2.5 services by ADA code per patient/visit

• Number of new patients should be similar to the number of completed treatments

Source: http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2015&state=

r

What is Everybody Else Doing?

Define Your Capacity

https://www.dentaquestinstitute.org/learn/safety-net-solutions

Prior to Setting Access Goals






Capacity=Quality

Defining Capacity • We are limited by our structure

– Chairs-Rooms-Ops., Dentists, DHTs, RDHs, DAs, Staff, Hours of Operation

• Our structure determines our capacity not our hearts

• We only have 20% of the capacity of Medicine

• We cannot be everything to every patient

• We need to decide WHO gets the care

• Equitable, quality, care mandates that we work within our capacity

• When we understand and define capacity we then create our business plan

• Our patient population

– Serve primarily adults, children or a mix?

• Provider skill levels

– Students/externs

– Recent graduates

– Advanced dentists

• Staffing Model

– General Dentists, RDHs, Pediatric Dentists, etc.

Other Considerations Impacting Capacity

The Business Plan

GOVERNANCE

QUALITY

There is Productivity in Access-Finance-Outcomes

Remember: We get what we measure And We get the results we tolerate

We now establish productivity goals for the program as a unit and for each individual

Remembering: Clarity around Goals, Roles, Responsibilities and Timelines establishes how we will hold the program and each individual

Accountable

Access – Finance – Outcomes

Access is not Visits!!!

Access is everything associated with the visit:

Visit Measures

Services: Type – diagnostic, preventive, therapeutic, specialty

How many services by ADA code?

Charges for the services

Revenue received for the charges

Health Outcomes as a result of the services

Quality of the services and of the customer service

Compliance with Governance

Safe-Equitable-Efficient-Effective-Timely-Patient Centric

Outcomes Health Outcomes

Oral Health Outcomes

Financial Outcomes

HRSA Goal Outcomes

Treatment Plan Completion Outcomes

Focus Population Care Outcomes

Access

Access – Finance – Outcomes

Creation of a high-quality, affordable, oral health program that documents the improvement of the oral health status of the patients we treat while being financially responsible

Finance

Vision

What the dental practice needs to accomplish to be financially sustainable, maximize patient access and provide meaningful quality outcomes

Financial Plan

REMEMBER: Knowing who you are and being able to

define that with data; defining who you want to be and what success looks like for you; creating a simple and clear plan to achieve that success and then communicating that plan to the team and thus creating a culture of accountability is the road to accomplishing financial success

The Profit and Loss

If I had only one report!

Benchmark Dental Budget Breakdown Total Budget: 100%

• Dental Practice Overhead: 70-85% • See breakdown below*

• Allocation for Administrative Costs: 5-10% • Costs for CEO, CFO, COO, etc.

• Health Center Support Allocation: 10-20% • Costs for Human Resources, Security, Medical Records, IT, etc.

Breakdown of the 70-85% Dental Practice Overhead: • Payroll (salary, taxes, & fringe benefits): 68% • Building, Utilities, telephone: 9% • Dental Supplies: 7% • Lab fees: 5% • Depreciation: 4%

• Office Supplies: 2% • Repairs: 2% • Marketing/Promotion: 1% • Recruitment: 1% • Continuing Education: 1%

JUNE

Actual Budget Variance Actual Budget Variance

Revenues:

Gross Charges 410,093 487,190 (77,097) 2,767,732 2,965,725 (197,993)

Insurance adjustments (145,552) (183,671) 38,119 (1,001,406) (1,118,078) 116,672

Grant Revenue 22,917 22,917 - 137,500 137,500 -

Capitation payments 4,446 5,198 (752) 27,113 32,034 (4,921)

Interest/Other Income - - - -

Total Revenues 291,904 331,634 (39,730) - 1,930,939 2,017,181 (86,242)

Expenses:

SALARIES & BENEFITS 232,954 238,549 5,595 1,464,196 1,413,315 (50,881)

COMMISSIONS - - - - - -

RENT, BUILDING EXPENSE, OFFICE EQUIPMENT 15,636 13,542 (2,094) 88,037 81,250 (6,787)

PRINTING & ADVERTISING - 250 250 1,548 1,500 (48)

POSTAGE & SUPPLIES 14,378 35,808 21,431 191,953 214,850 22,897

TELEPHONE 2,574 1,708 (865) 6,620 10,257 3,637

OPERATIONAL EXPENSE 2,855 1,542 (1,313) 19,907 9,250 (10,657)

PROFESSIONAL SERVICES & CONSULTING 17,224 18,417 1,193 114,384 110,500 (3,884)

INITIATIVES - - - - - -

COMPANY INSURANCE - 2,900 2,900 7,776 5,800 (1,976)

TRAVEL - 67 67 262 400 138

MISCELLANEOUS 2,721 3,193 471 10,561 10,357 (205)

DEPRECIATION 30,722 32,223 1,500 186,287 193,336 7,049

Total Expenses 319,064 348,198 29,134 2,091,533 2,050,815 (40,718)

Change in Net Assets (27,160) (16,563) (10,597) (160,594) (33,634) (126,960)

Month - To - Date Year - To - Date

JUNE

39

Variance Report

What Data Should We Collect?

Number of Visits

Gross Charges

Net Revenue

Expenses

# of Services(CDT)

Revenue per Visit

Cost per Visit

Services per Visit

Broken Appointment Rate

Emergency Rate

# of Completed Treatments

% Children seen Receiving a Preventive Service

A/R out 90 days

Top Priorities for Dental

1. Understanding What Success Should Look Like in Dental

2. Compiling data that is: Accurate, Meaningful and Timely

3. Computing and understanding your actual “Capacity”

4. Setting clear Goals, Roles, Responsibilities and Timelines

5. Utilizing the dental schedule strategically

6. Having the right policy for “Everything”

7. Owning management of Broken Apts & Emergencies

8. Creating a “Culture of Accountability”

9. Executing a CQI and QA System

10. What your own Executive Leadership should look and feel

like to best enable and support Dental

Outcomes • HRSA Sealant Measure Compliance

• Phase 1 Completed Treatments

• Children seen 0-5 years old

• Children seen getting preventive service

• Diabetic patients with HbA1C > 7 seen

• Formal referral policy with Primary Care

• % emergency treatments

• Sealants provided………….

http://www.nnoha.org/nnoha-content/uploads/2015/12/Demystifying-HRSA-SEALANT-PRESENTATION_FINAL.pdf

Quality • Quality Management System

• Quality Assurance Policy and Tool

• Continuous Quality Improvement Policy

• Credentialing Policy

• Privileging Policy/Competencies

• Policy and Procedure Manual

• Customer Satisfaction Survey (1 X Year)

• QA and CQI policies • Chart audit process • Addressing Patient Complaints • Infection Control/Sterilization/Spore Testing • HIPAA • Dental Emergency Access • Scheduling • Incident Reporting • Occupational Exposures • On-boarding of new staff (Orientation/Training)

Policies and Procedures

• Can use a paper form – example: http://dentalclinicmanual.com/docs/Patient_Survey3.pdf

• Must have a valid # surveys /per provider

• Must report the results to the staff ( Staff Meeting)

• Must act on results: document actions

Patient Satisfaction Surveys

http://dentalclinicmanual.com/docs/Patient_Survey3.pdf



• ADA Radiograph guidelineshttp://www.ada.org/~/media/ADA/Member%20Center/FIles/Dental_Radiographic_Examinations_2012.ashx

• ADA Clinical Practice Guidelines http://ebd.ada.org/en/evidence/evidence-by-topic

• American Association of Endodontists: http://www.aae.org/colleagues/

• American Academy of Pediatric Dentistry: http://guideline.gov/browse/by-organization.aspx?orgid=874

• Agency for Healthcare Research and Quality (135 dental guidelines) http://www.guidelines.gov/search/search.aspx?term=dentistry

• ADA code of ethics and conduct www.ada.org/about-the-ada/principles-of-ethics-code-of-professional-conduct

Guidelines

http://ebd.ada.org/en/evidence/evidence-by-topic






http://www.aae.org/colleagues/

http://guideline.gov/browse/by-organization.aspx?orgid=874




http://www.guidelines.gov/search/search.aspx?term=dentistry

http://www.ada.org/about-the-ada/principles-of-ethics-code-of-professional-conduct

















• Friendliness of ALL staff

• Timely appointments

• Wait times in the waiting room

• Provider: listening

• Provider addressing their concerns

• Appearance of the office

• No pain!

• Understanding the bill!!!

• Good communication

Issues Most Important to Patients

Governance • Compliance with Federal, State and Local Regulations and with

the State Practice Act

• Compliance Officer

• Policy and Procedure Manual

• Privileging Policy/Competencies

• Annual Safety/infection Control/ Hazardous Waste Training

• Preparation for a HRSA Operational Site Visit (OSV)

• Nominal fees and Sliding fees

• After Hours Coverage Policy

• Off Hours Service Hours

• HRSA Pin 2002-22 Requires Credentialing and Privileging of providers including dentists.

• Credentialing is the process of establishing and ensuring that a provider is qualified to practice in your center.

• Your health center should own and control the credentialing process

• Privileging is establishing the right of a provider to perform specific procedures

• The Dental Director should own and control the privileging process

• Defines, for the incoming dentist, what procedures are allowed at the clinic and for that dentist

• Required for FTCA insurance and many other malpractice insurers

Credentialing and Privileging

Accessible Hours of Operation/Locations:

Health center provides services at times and locations that assure accessibility and meet the needs of the population to be served. (Section 330(k)(3)(A) of the PHS Act)

After-Hours Coverage: Health center provides

professional coverage during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act)

Operational Site Visit Dental Compliance Issues

Budget: Health center has developed a budget that

reflects the costs of operations, expenses, and revenues (including the Federal grant) necessary to accomplish the service delivery plan, including the number of patients to be served. (Section 330(k)(3)(D), Section 330(k)(3)(I)(i), and 45 CFR Part

74.25)

Scope of Project: Health center maintains its funded

scope of project (sites, services, service area, target population, and providers), including any increases based on recent grant awards. (45 CFR Part 74.25)


Sliding Fee Discounts: Health center has a system in place to determine

eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. This system must provide a full discount to individuals and families with annual

incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.*

No discounts may be provided to patients with incomes over 200% of the Federal poverty guidelines.*

No patient will be denied health care services by the health center due to an individual’s inability to pay for such services, assuring that any fees or payments required by the center for such services will be reduced or waived. (Section 330(k)(3)(G) of the PHS Act, 42 CFR Part 51c.303(f)), and 42 CFR Part 51c.303(u))


Federal Tort Claims Act (FTCA) • FTCA applies to employees of eligible health centers. key

words – employees and eligible.

• To receive FTCA coverage, a health center has to be deemed. To become deemed, a health center has to apply and go through the deeming process.

• Until a health center is deemed to have FTCA coverage, they must have private malpractice insurance.

• Deeming health center program grantees are immune from medical malpractice lawsuits resulting from the performance of medical, surgical, dental or related functions within the approved scope of project. Key words, approved scope of project

• *Volunteers in cases of emergency situations starting in 2018 can be covered by the FTCA programs (temporary employees and volunteers can be covered according to the new PAL 2017- 06 and 2017-7)

Federal Tort Claims Act (FTCA) • Federal employees as employees of qualified health centers

are immune from lawsuits. The Federal government acts as their primary insurer

• Eligible health centers must apply for FTCA coverage. Eligibility would include health center grantees funded under section 330 of the Public Health Service act (PHS) including CHC’s, MHC’s, HCH HC’s and PHC’s. All eligible health centers must apply for FTCA coverage. All employees and qualified contractors that are deemed are covered by FTCA

• All licensed or certified health center providers who work or volunteer in a health center must undergo a credentialing or privileging process in accordance with PIN 2002-22

• Deemed health centers must have and submit a QI/QA plan

• The health center’s QI/QA plan must be reviewed by the Board every 3 years.

New BPHC Guidance Resources

• 2017 HRSA Health Center Compliance Manual

– https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html

Questions?

Planning for Dental Program Success,

Part 1: The Mission

How to use data to create an action plan for success!

Junior Accountant, Computerized Bookkeeping, LLC

Accounts Payable Supervisor, W.B. Mason

Senior Project Manager, Safety Net Solutions, 2008-present

Danielle Apostolon, B.A. Business Management Senior Project Manager, Safety Net Solutions DentaQuest Institute

Member, American Association of Public Health Dentistry

Associate Member, Association of State and Territorial Dental Directors

Member, National Network for Oral Health Access

• Recognize the key practice data necessary to establish realistic goals and review dental program performance relative to productivity

• Understand how to perform calculations that provide meaning behind the data

• Identify how to define dental program capacity, access and productivity

• Determine how to set realistic and achievable productivity goals

Learning Outcomes

• Establish a baseline from which to start

• Shift from what is thought to be happening to knowledge of what is really happening

• Allows monitoring of procedural changes to ensure that improvements are sustained

• Indicates whether or not changes lead to improvements and helps to identify ineffective solutions

• Allows comparisons of performance across sites

Why Data is Important

Dental Visits

Dental Procedures

Unduplicated Patients

New Patients

Broken Appointments

Emergencies

Access in Productivity Metrics

Benchmarks

• 2500-3200 encounters/year/FTE dentist

• 1500-1800 encounters/year/FTE hygienist

• 1.7 patients/hour or 13.6 patients per 8-hour day per dentist

• 1.2 patients/hour or 8-10 patients per 8-hour day per hygienist

Dental Visits

Benchmark Guide

Determining Capacity Goals Based on Our Structure

# of

Providers

# of total

clinical hours worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

Potential Weekly Capacity = 135 Dentist Visits

Actual

Visits

% of

Capacity

Achieved

20 74%

26 96%

19 70%

18 66%

10 37%

*At least two operatories and 1.5 dental assistants

Setting Productivity/Access Goals: Visits Potential vs. Actual Capacity – FTE Dentists

# of

Providers

# of total

clinical hours worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 1 8 1.2 9

Tues. 1 8 1.2 9

Wed. 1 8 1.2 9

Thurs 1 8 1.2 9

Fri 1 8 1.2 9

Potential Weekly Capacity = 45 Hygiene Visits

Actual

Visits

% of

Capacity

Achieved

7 77%

8 89%

6 66%

7 77%

6 66%

*Benchmark of 1.2 is ideal for a practice with a patient mix of both adults and children

Setting Productivity/Access Goals: Visits Potential vs. Actual Capacity – FTE Hygienists

GOAL CALCULATION TARGET

Visits/Day 27 Dental Visits + 9 Hygiene Visits = 36 visits per day *same for each day

36

Visits/Week 135 Dental Visits + 45 Hygiene visits = 180 visits per week

180

Visits/Year 180 weekly visits x 46 weeks = 8,280 Visits

8,280

Dental Visits Based on Capacity

Potential Weekly Capacity = 110 Dentist Visits

Model 1: 2 Dentists each working out of 2 Operatories with 1 dental assistant

Comparison

Model 2: 2 Dentists each working out of 2 Operatories with 1.5 dental assistant

Impact on Access

# of Providers

# of total clinical hours worked

x recommended # of visits/ clinical hour

Potential Daily Visit Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

# of Providers

# of total clinical hours worked

x recommended # of visits/ clinical hour

Potential Daily Visit Capacity

Mon. 2 16 1.4 22

Tues. 2 16 1.4 22

Wed. 2 16 1.4 22

Thurs 2 16 1.4 22

Fri 2 16 1.4 22

110 Visits per Week

135 Visits per Week

Cost Benefit 25 Additional Visits • 20% Self pay visits = 5 @ $40 =

$200 • 65% Medicaid visits = 17@ $135

= $2,295 • 10% Commercial Insurance = 3

@ $165 = $495 • 5% Homeless (Free Care) = $0

Total Revenue = $2,990

Salary

• $16/hour x 40 hrs = $640/week

• Fringe benefits @ 25% = $160

• Total cost = $800/week

Cost of Providing Care

• 25 Visits x $10/visit=$250

Total Cost=$1,050

Cost vs. Benefit of Adding Dental Assistant

Weekly profit = $1,940

Yearly profit = $108,680

Increases access by providing nearly 1,150 additional visits for the year!

The total number of procedure

• CDT codes and dummy codes such as denture try-ins and suture removal

Scope of Service

• Percentage of each type or service provided

Procedures per visit

• Total Procedures Total Visits

Dental Procedures

Service Type Procedure Codes % of Total

Diagnostic D0100-D0999 (excluding D0140)

35%

Preventive D1000-D1999 33%

Restorative D2000-D2999 20%

Specialty (endo/perio/prostho)

D3000-D6999 2-6%

Oral Surgery D7000-D7999 5-10%

Emergency D0140, D9110 2-6%

Scope of Service Benchmarks

Time Providers level of competency

Patient need

Patient tolerance

Reimbursement

Considerations

Benchmark for procedures per visit: 2.5

Total the number of procedures by ADA code and divide that by the total number of yearly visits

• Total annual visits = 3,600

• Total procedures by ADA/CDT code = 4,000

• 4,000/3,600 = 1.1 procedures per visit

Dental Procedures

Too Many:

•Overwhelming demand and trying to take care of too many patients

•Working beyond your capacity

•Patients are unable to return for care to complete their treatment

Too Few

•Lack of demand and trouble filling the schedule

•Patients could be unhappy with the care

•Competition in the area

•Not enough patients to draw from (lack of needs assessment prior to opening)

Unduplicated Patients

Benchmark:

• 1,100-1,200 unduplicated patients per FTE General Dentist

• 2.5 visits/year per unduplicated dental patient

Calculation Target

Example 1 2 FTE Dentists x 1,100 2,200

Example 2 8,000 ÷ 2.5 3,200

Unduplicated Patients, Cont.

Number of new patients is measured by the number of comprehensive dental exams (D0150)

The number of new patients should equal the number of patients you completed treatment on

Need to determine the number of new patients the practice can manage

Too many or too few are both problematic

New Patients

Indicators that you may be bringing in too many new patients:

• Increased length of time between exams (treatment plan creation) and the completion of phase one treatment

• Decrease in the % of completed treatments plans

• The dental schedule is booked out past 2 months

• Increase in the broken appointment rate

New Patients, Cont.

• Too many new patients are coming into the practice

• Appointment lengths are too short

• Lack of policy and protocol for managing emergencies

• Scheduling issues (i.e. staff not familiar with appointment type and length)

• Lack of documented & sequenced treatment plans

• Communication issues between providers and front office staff

• Intentional or unintentional practice of churning visits

Productivity Busters

• No-shows and last-minute cancellations

• Practice overrun with emergencies

• Is the practice chaotic and patient visits are unpredictable due to high number of walk ins with or without emergent care?

• Lack of goals and accountability

• Individual provider issues (unmotivated, inexperienced, health problems, life issues, etc.)

• Equipment issues (outdated, missing, broken)

• Lack of EDR/PMS (or not being used maximally)

Productivity Busters, Cont.

Action Steps that Lead to Improvement

• Develop a strong broken appointment policy • Determine how many broken appointments will be

allowed and in what time period • Determine what the consequences will be of failing the

policy • Designate approach to late patients • Don’t schedule appointments out past 30-45 days

(including hygiene patients) • Don’t make multiple appointments at the same time

(except for RCTs, dentures)

Manage Broken Appointments

• Define goals for the dental program and for each provider • Visits/Day • Visits/Week • Visits/Year

• Practice leadership should run daily, weekly and monthly reports to determine number of visits, compare against goals and provide ongoing feedback to dental staff

• Providers should be rewarded for attaining access, financial and outcomes goals

• Rewards can be distributed quarterly, semi-annually or annually

• Add additional dental assistant staff • Optimal is 2 ops & 1.5 FTE DAs per dentist

Increase Access

• Develop clinical protocols for each patient visit type

• Define standard appointment type lengths for each visit type

• Use the schedule to maximize access and foster the timely completion of phase 1 treatment plans

Increase Access, Cont.

• Consider the following priority population groups: • Children • Pregnant women • Patients with specific medical needs (physician’s note) • Established medical patients of the CHC

• Access to care is prioritized to these patients • New patients and emergency patients who are not

established dental patients of record are accommodated to the extent possible without interfering with the care of priority patients

Manage Capacity

Lunch

• Open the SNS Financial and Productivity Goals Tool Excel spreadsheet (1st tab – Productivity Goals Exercise)

• Using the Productivity Benchmark Guide & Your Data Sheet for Financial and Productivity Goals Exercise, we are going to identify the following productivity goals:

• Visits per day

• Weekly visits per provider

• Visits per week

• Visits per year

Exercise 1: Develop Productivity Goals

Step by Step Instructions 1. Change the “Provider Type” column headings & enter the names of your providers. 2. Using the productivity benchmark guide enter the visit per hour benchmark

for each provider. 3. Refer to your Provider Schedule from your Data Sheet and enter the daily

clinical hours for each provider.

• The daily visit goal for each provider will automatically calculate. • The weekly visit goal for each provider will automatically calculate in cells C16-F16. • The daily visit goal for the clinic will automatically calculate in column H. • The weekly visit goal for the clinic will automatically calculate in cell H17.

4. Enter the number of weeks per year in cell J18.

The yearly visit goal will automatically calculate in cell H20.

*You will use the yearly visit goal in the next exercise

Determining Benchmark/Hour

Questions?

Planning for Dental Program Success, Part 2

The Margin: Understanding Finance in Dental

95

Associate Vice President, Morton Hospital and Medical Center, 1992-2006

Publications Coordinator, Norwood Hospital, 1986-1992

Freelance Editor, 1982-1986

President, Board of Directors, Taunton Oral Health Center, 2008-present


Dori Bingham Program Manager, Safety Net Solutions DentaQuest Institute



• Recognize the key practice data necessary to establish realistic goals and review dental program performance relative to finance

• Identify how to perform calculations that provide meaning behind the data

• Determine how to set realistic and achievable financial goals

• Identify specific areas in need of a redesign using data

• Identify solutions to common issues that impact dental program success through data and an understanding of the five domains

Learning Outcomes

GROSS CHARGES

NET REVENUE

EXPENSES

ACCOUNTS RECEIVABLE

COLLECTION RATE

PAYER MIX

Financial Metrics

Clinic Data and Reports Needed

• Profit and Loss Statement

• Aging Report

• Transaction/Productivity by Procedure Report

• Payer Mix

• Collection Rate

Balancing the Mission and Margin

Expenses Revenue

• Staff

• Cost Provide Care

• Overhead

• Visits

• Payer Mix

• Grants & Donations

Define Financial Success • Create a surplus?

• Break even or zero variance?

• With grants or without grants?

• Willing to accept a loss? If so how much?

Goal Calculation Target

Revenue per Year Total direct and indirect expenses for the year = break-even; with grants

$800,000

Revenue per Week $800,000 ÷ 46 Weeks $17,391

Revenue per Day $800,000 ÷ 230 Days

$3,478

Revenue per Visit $800,000 ÷ 8,050 Visits

$99

Break-even with grants: Total expenses

of $1,050,000 - $250,000 in grants =

$800,000

Calculating Net Revenue Goals

Benchmark

• $450,000-$550,000 per year per FTE Dentist

• $250,000-$350,000 per year per FTE Hygienist

Calculating Gross Charges Goals

Goal Calculation Target

2 FTE Dentists 2 x $550,000 $1,100,000

1 FTE Hygienists 1 x $350,000 $350,000

Gross Charges per Year $1,450,000

$1,450,000

Gross Charges per Week

$1,450,000 ÷ 46 Weeks

$29,348

Gross Charges per Day $1,450,000 ÷ 230 Days

$5,870

Gross Charges per Visit $1,450,000 ÷ 8,050 Visits $168

Individual Production Goals Provider FTE Gross

Charges Net Revenue (60%)

Annual Days Worked

Charges/Day

Revenue/Day

Dr. A 1.0 $550,000 $330,000 230 $2,391 $1,435

Dr. B 1.0 $550,000 $330,000 230 $2,391 $1,435

Total Dentist 2.0 $1,100,000 $660,000 460 $4,782 $2,870

Hygienist A 1.0 $350,000 $210,000 230 $1,522 $913

Total Hygienist

1.0 $350,000 $210,000 230 $1,522 $913

Overall Clinic Goals

$1,450,000 $870,000 230 $6,304 $3,783

Predictability is Key Standardization Leads to Predictability

• Patient/Payer Mix

• 3rd Party insurance reimbursement

• Sliding fee discounts and nominal fees

• Visits

Payer Mix • Huge impact on financial sustainability

• Big challenge to manage

• Determine the average revenue per visit per payer type

• Use that information to create a payer mix that ensures financial sustainability while preserving access for all patients

7,500 visits

35% Medicaid =2,625 visits x $100 = $262,500

55% Self-Pay/SFS =4,125 visits x $30 = $123,750

10% Commercial =750 visits x $125 = $93,750

Total revenue = $480,000

Total expenses = $500,000

Operating loss = ($20,000)

7,500 visits

40% Medicaid =3,000 visits x $100 = $300,000

50% Self-Pay/SFS =3,750 visits x $30 = $112,500

10% Commercial=750 visits x $125 = $93,750

Total revenue = $506,250

Total expenses = $500,000

Operating surplus = $6,250

Impact of Payer Mix on Sustainability

Average Reimbursement by Payer Type

Payer Mix • Designate public health and/or medically indicated

priority populations and work to get them into the practice

• Pregnant women and children are two populations more likely to have insurance coverage

• Goal to preserve as much access for uninsured patients as possible while maintaining financial sustainability

• Being financially sustainable lays the groundwork for expansion, which increases access for all payer types

• Use data and knowledge of the practice to inform decisions around patient and payer mix!

Obstacles to Success

• Unfavorable payer mix • Working under or over capacity • Lack of goals and accountability • High broken appointment rate • Scheduling issues (types of patients) • Insufficient support staff (dental assistants) • Staff turnover • Insufficient instruments, supplies • Equipment issues (chairs, outdated, missing, broken) • Lack of EDR/PMS (or not being fully utilized) • Billing and collections • Fees are set too low

Amount of money owed to the practice for services

Marker for how well the billing process is working

Marker for whether the dental staff is consistently collecting co-

pays at the time of the visit

Accounts Receivable

Aging Report

Productivity Busters: Empty chairs = missed opportunities

Reimbursement environment:

Low encounter rate or fee for

service

Issues in the billing &

collections process

Fee schedule & SFDS/Nominal

fee: Fees below market rate,

nominal fee too low

Patient/Payer Mix: high

number of uninsured adult

patients

Common Factors Impacting Finance

Billing and Collections

•Bring together a multidisciplinary team with representatives from dental billing, finance and others who play a role in the billing process to meet on a regular basis—make this a formal Performance Improvement Team

•Review and flow chart the entire billing process, identifying the staff person or position responsible for each step in the process

•Establish performance measures to monitor the success of the billing process

Manage Self Pay Patients

•Review systems and processes for self-pay/SFS patients

•Review/create policy defining all aspects of payment for dental care

•Educate patients about why payment is required at the time of the visit

•Develop scripting for staff to use in communicating with patients

•Alert front desk staff that A/R past 90 days from self-pay/SFS patients is a measure used to evaluate their performance

•Set ceiling targets for A/R, monitor, provide feedback to staff and manage performance issues

Action Steps: Improve the Billing & Collections Process

Designate priority populations and work to get

them in the practice

Goal: to preserve as much access for uninsured

patients as possible while maintaining financial

sustainability

Action Steps: Tweak Payer Mix

Increase the fee schedule to at least the 70th – 80th percentile of usual and customary fees

SNS recommends creating a fixed flat-rate (1x per visit) nominal fee and applying the nominal fee only for patients at or below 100% FPL

Action Steps: Revise Fee Schedule

• Open the financial goals worksheet in the Excel spreadsheet (2nd tab)

• Using your dental clinic’s total expenses & number of clinic days per year from your data worksheet, we will determine the break-even goal by identifying the following:

• Revenue per week

• Revenue per day

• Revenue per visit

• Weeks per Year = 46

• Number of clinic days per year = Your weekly clinic days x 46 weeks

• Compare the Revenue per visit goal to your cost per visit

Exercise 2: Develop Financial Goals

Financial Goals

Instructions Description of Goal Variables Goal

Enter total indirect and direct

expenses from the profit and

loss statement the most recent

fiscal year Yearly Revenue Goal -$

Enter number of weeks/year Weekly Revenue Goal #DIV/0!

Enter Number of Clinical Days

per Year Daily Revenue Goal #DIV/0!

Enter yearly visits from the

productivity goal exercise Revenue Per Visit #DIV/0!

Goal 1: Break Even Goal without Grants

Determine Yearly Revenue Goal

Establishing Financial Goals Using Tool

• Open the payer mix projection tool 2016 worksheet

• We will use the yearly visit goals calculated from the productivity goals exercise & your dental clinic’s payer mix from your data worksheet and the reimbursement rates below to complete this portion of the activity

• Reimbursement rates:

– Medicaid = $125

– Self Pay= $60

– Commercial= $185

– Other = $85

Exercise 3: Develop Financial Goals, Cont.

Payer Mix Tool

Financial Projections Projected Visits

Actual Visits

Difference

Patient/Insurance mix: Yearly visits

Percent Medicaid -

Percent Self Pay -

Percent Commercial Insurance -

Percent Other -

Total 0% -

Reimbursement Rate (per visit): Yearly Revenue

Medicaid $ -

Self Pay $ -

Commercial Insurance $ -

Other $ -

Total Projected Revenue $ -

Total Expenses

Projected Bottom Line $ -

Payer Mix

Questions?

Break

Payment and Care Delivery Reform in the Healthcare Safety Net

William Riley, PhD, Director of the National Safety Net Advancement Center

Winston-Salem, North Carolina

December 1, 2017

Professor in the School for the Science of Health Care Delivery at Arizona State University (ASU). Director of the National Safety Net Advancement Center. Previously the Associate Dean for the School of Public Health at the University of Minnesota Bill is a former health care executive with more than 20 years of experience as a president and CEO of a Blue Cross Blue Shield of Minnesota subsidiary, a large multispecialty medical group, and an integrated delivery system.

William Riley, PhD Professor, School for the Science of Health Care Delivery Director, National Safety Net Advancement Center Arizona State University

Bill has led quality improvement collaboratives in over 200 hospitals, health care systems, and public health departments. Bill is the author of over 100 articles related to quality improvement and the implementation of health care bundles to improve systems performance, and is co-author of two books on applying quality improvement methods and techniques in health care.

Objectives

• Differentiate between strategy and efficiency

• Explain Health Care Payment Reform Priorities

• Identify Payment Reform Problems and Solutions for Oral Health

Health Care Payment Reform

• Paradoxes

• Severe Market Failure

Health Status: Determinants of Health and Health Care Expenditures

Access to

Care

Environment

Genetics

Health

Behaviors

Access to

Care

Other

Health

Behaviors

Influence National Health Expenditures

$3 Trillion

10%

20%

20%

50%

88%

8%

4% Source: Centers for Disease Control and Prevention, University of California at San Francisco,

Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm

Health Status: Determinants of Health and Health Care Expenditures

Source: Centers for Disease Control and Prevention, University of California at San Francisco,

Institute for the Future, http://www.cdc.gov/nchs/fastats/health-expenditures.htm

Access to

Care

Environment

Genetics

Health

Behaviors

Access to

Care

Other

Health

Behaviors

Influence National Health Expenditures

$3 Trillion

10%

20%

20%

50%

88%

8%

4%

Health Care Payment and Care Delivery Reform…and the Implementation for Oral Health • Structure of Health Care System Today

– How is it designed?

– Social/Historical/Political/Economic Factors

• Heliocentric and Geocentric Perspective

Key Strategy Questions 1. What is the goal of the health care oral health system?

2. Is the system (policy, financing, structure, education, organization) designed to achieve this goal?

3. Health system or sickness system?

North Carolina Safety Net Sector Primary Care to the Uninsured

Clinic Site Patients Served (annually)

Percent Uninsured

FQHC 471,252 42.4%

Health Department 518,646 37.2%

RHC 82,898 13.3%

Total 1,072,887 30.9%

Oral Health Value Based Financing and Care Delivery Discussion Questions

1. What do you want for the oral health priorities for you and your family?

2. To what extent are the oral health needs of your community addressed?

3. To what extent do you practice at the top of your license?

Source: MACPAC. Medicaid’s share of state budgets. https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/

0

5

10

15

20

25

30

1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Per

cen

tage

of

Tota

l Sta

te E

xpen

dit

ure

s

State Fiscal Year

Medicaid Expenditure As Share of Total State Expenditures, 1989-2015 (State and Federal)

https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/









The Value Equation

Value = Quality

Cost

Health Care Finance

• Prospective Payment

– Pays for value

• Retrospective Payment

– Pays for volume

Payment Reform Milestones • Affordable Care Act (2010)

– Access through Medicaid Expansion and Insurance Exchange

– Authorized Accountable Care Organizations

– Modest Insurance reforms

• MACRA

– 2015

– HHS launched the LAN (on March 25, 2015) to help advance the work being done across sectors to increase the adoption of quality-based payments and alternative payment models

Category 1

Fee for Service –

No Link to

Quality & Value

Category 2

Fee for Service –

Link to

Quality & Value

Category 3

APMs Built on

Fee-for-Service

Architecture

Category 4

Population-Based

Payment

A

Foundational Payments

for Infrastructure &

Operations

B

Pay for Reporting

C

Rewards for

Performance

D

Rewards and Penalties

for Performance

A

APMs with

Upside Gainsharing

B

APMs with Upside

Gainsharing/Downside

Risk

A

Condition-Specific

Population-Based

Payment

B

Comprehensive

Population-Based

Payment

Population-Based Accountability

The framework situates existing and potential APMs into a series of categories.

The Framework is a critical first step toward the goal of better care, smarter spending, and healthier people.

• At-a-Glance

APM Framework

3N Risk-based payments NOT

linked to quality

4N Capitated payments NOT

linked to quality

= example payment models will not count toward APM goal.

N = payment models in Categories 3 and 4 that do not have a link to quality and will not count toward the APM goal.

https://hcp-lan.org/groups/apm-fpt/apm-framework/

Better Care, Smarter Spending, Healthier People

Adoption of Alternative Payment Models (APMs)

These payment reforms are expected to demonstrate better outcomes and smarter spending for patients.

In 2018, at least 50% of U.S. health care payments are so linked.

2018

50%

In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs.

2016

30%

Goals for U.S. Health Care

Our Goal

Value Equation:

Value = Quality/Cost

Formula 1 Pit Stops 1950 & Today

Opportunities for Alternative Payment

1. Providers focus on improving population health

2. All providers practice at top of their license

3. Providers get paid for what they do not do

4. Fewer benefit restrictions and limitations

Secondary Prevention - Remineralization

Winston AE, Bhaskar SN. Caries Prevention in the 21st Century. JADA, Vol. 129, Nov ’98: p1579-1587

D2150 $122 D2392 $199 Remineralization $0

Institute of Medicine (IOM) definition of quality of care: "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Oral Health And The

Dental Benefits were designed in the 1960`s

Study with Navigant

Fee-for-Service in Dental Rewards Invasive Care

Prophy Amalgam Composite Crown

Fee $64 $92 $152 $1,100

Cost of service $175

Net $64 $92 $152 $925

Time (hours) 0.5 0.5 0.67 1.5

Gross hourly rate $128 $184 $228 $617

Overhead cost/hr $140 $120 $120 $120

Net hourly Income ($12) $64 $108 $497

Profit in 8 hour day ($96) $512 $864 $3,973

Annualized Profit/Loss ($21,600) $115,200 $194,400 $894,000

550 N 3rd St, Phoenix, AZ 85004 Tel: 602.803.4228 Safetnet.asu.edu

Thank you!

Questions?


Closing/Wrap-Up

Welcome Recap of Day 1 & Day 2 Overview

Today’s Presenters

• Ann Cadoret, RDH, MSDH, Project Manager, Safety

Net Solutions

• Dori Bingham, Program Manager, Safety Net

Solutions

• Danielle Apostolon, Senior Program Manager, Safety

Net Solutions

• Caroline Darcy, Project Manager, Safety Net

Solutions

Today’s Agenda

Welcome - Recap of Day 1 and Day 2 Overview

Managing Chaos: Broken Appointments and Emergencies

Managing Chaos Exercise

Break

Strategic Scheduling


Lunch

Today’s Agenda

Staffing for Success

Creating an Improvement Plan

Group Activity: Identify Areas for Improvement

Closing/Wrap-Up & Post Training Evaluation

Managing Chaos Broken Appointments and Emergencies

Dental Assistant – 1999 – 2016

Dental Office Project Manager – 1999- 2016

Dental Hygienist – 2004 – present

Master’s of Science Degree

Master’s Degree in Public Health (candidate)

Published author – Health and Interprofessional Practice

Missions of Mercy volunteer 2012 - present

Ann Cadoret, RDH, MS Project Manager, Safety Net Solutions DentaQuest Institute

Member, American Dental Hygiene Association

Member, Rhode Island Dental Hygiene Association


Associate Member, American Academy of Pediatric Dentistry

Managing Emergencies

• Emergency care is an important safety net service, but our capacity for emergency care must be managed

Understand that your Capacity is Limited!

• Comparative Situation: • Antibiotics for 5 patients, but instead try to treat 10 patients

• Results: • “Band-Aid” solution • 10 patients get only half the care = episodic, fragmented,

not patient-centered or ethical care

• What happens if your clinic has the capacity to treat 5,000 dental patients and you try to provide care to 10,000 patients?

• Use data to determine the level of demand for your emergency care

• Create a system to MANAGE emergencies

• Don’t let your emergencies manage YOU

• Know your capacity!

• Options: Designated providers, designated chairs, block scheduling, etc.

• Morning huddle

Emergency Care Management

Manage Emergency Care If demand for emergency care greatly exceeds your capacity, you will need to make management decisions:

1. Define your “service area” 2. Only see patients of record (require prevention) 3. Consider a waivered patient policy 4. Equally distribute demand with other

organizations

#s 1-3: FQHC’s: Check your scope of project. See also HRSA PIN 2008-01

Create an Emergency Policy

• Define what a true emergency is • Create a triage form • Create a scheduling template for

emergencies • Provide scripting to staff • Train all staff on what your emergency

policy is

#s 1-3: FQHC’s: Check your scope of project. See also HRSA PIN 2008-01

• Understand your true current demand for emergency care

• Develop an emergency management system to meet the current demand

• Create an emergency policy and triage tool • Define a true emergency • Explain capacity limitations • After-hours emergencies

• Be consistent; provide annual staff retraining

Keys for Managing Emergencies

Managing Broken Appointments

No-Shows: A patient is scheduled for an appointment and

they do not show up for that appointment.

Late

Cancellations:

A patient cancels an appointment less than 24

hours prior to the start of the appointment.

Late Arrivals: A patient does not arrive by 10 minutes after

the start of their appointment.

Broken Appointments Defined

Appointment is Broken

Filled with Walk-ins & Emergencies

Daily Financial Goal is Missed

• Late Cancellation (<24 hours)

• No-show/late arrival (+10 mins)

• Logjam at Front Desk:

• New patient paperwork

• SFDS eligibility?

• Insurance eligibility?

• All Self-Pay

• $0 Collections

The Chain Reaction of Chaos

• #1 cited problem from all safety net dental clinics

• 5 Key Areas Negatively Impacted:

Access to Care

Oral Health Outcomes

Staff Satisfaction

Patient Satisfaction

Financial Sustainability

The Problem – Broken Appointments

Factors Likely to Increase Broken

Appointment Rates

• Lack of a clear understanding of the widespread effects broken appointments have on the practice • Not recognizing how broken appointments detract access from faithful patients • Failure to relate broken appointments to financial responsibility

• Improper interpretation of governance related to broken appointments • Absence of a broken appointment policy, a policy that is weak, or a policy that

is not enforced • Failure to train staff to enforce and document broken appointments • Patients who have not been held accountable and a perceived culture that

broken appointments are acceptable • Not having consequences for broken appointments; in particular not requiring

a proactive patient response

• It must be culturally competent

• Clarity:

• How your clinic defines “broken appointments”

• The confirmation process

• The consequences of not abiding by the policy

• Considerations for children under age 18

• Children can’t drive themselves, so aren’t necessarily the ones breaking the appointment

Keys to an Effective Broken Appointment Policy

• Require a proactive response: (options) 1. Broken appointment retraining session

2. Write a letter to the Dental Director

• After the second chance is used: (options) 1. Dismissal letter (30 days emergency care access)

2. “Same day only” status

• Quick call lists

• Pilot test and tweak

Effective Policies Require Strong Consequences

• Every patient should be given a copy of the Policy to read and sign. • Keep a signed copy in every patient’s chart.

• Remind patients of the policy when every appointment is scheduled.

• Post Broken Appointment Policy in the reception area.

• Consistent enforcement is imperative

for impartiality. • We want to change the culture of

patients feeling as though they can break the appointments with no consequences

Educate Patients

• After 5 minutes: the patient is called. (create scripting)

• After 10 minutes: the appointment is provided to another patient who is waiting.

• If the patient shows up provide them with 2 options: • Sit and wait –or–

• Reschedule (1st offense)

• If a patient breaches the policy: • Document the incident in their chart

• Flag accounts of repeat offenders

• Send a letter EVERY time a policy breach occurs

The No-Show/Late Arrival Protocol

Reduce the Risk of “No-Shows”

• 3 patient types with the highest risk for being a no-show

• New patient visits

• 6 Month recare visits

• Emergency visit follow-up appointments

• Require new (non-emergent) patients to register in person prior to first scheduled appointment

• Limit the number of new patients

• Do not book new patient visits out later than 2 weeks

Managing New Patient Visits

Managing Hygienist’s Visits

• Teach patients to value the hygiene visit

• Consider moving to a “designated access” 2-5 week schedule for hygiene patients

• Give patient a “due card” not an appointment card

• Clinic send postcards and make calls to schedule

• Require emergency patients who need follow-up care to call

• If follow-up care is important to the patient they will call to schedule

• If the patient did not value that appointment they would not have shown up, whether or not it was scheduled.

• Result: potential no-shows are prevented and appointments are reserved for patients who will show up

Emergency Care Follow-Up Visits

• Reminder calls: • Make the reminder call 48 hours in advance

• Consider an automated reminder system

• Schedule one follow-up appointment at a time

• Avoid making multiple appointments for family members on the same day • Never do this for new patients

• Faithful patients can earn this privilege

Other Methods to Reduce Potential No-Shows

• Some dental clinics double-book (or even triple-book) • What happens if both patients show up? (or all 3??)

• If you choose to double-book, do so “judiciously” by only double booking against unreached, unconfirmed appointments

• If you wish to do this, consider changing your policy to say you require confirmation

What About Double Booking?

• The ADA has two CDT codes to help dental programs track missed appointments and cancelled appointments: • D9986: missed appointment

• D9987: cancelled appointment

• To track walk-in/same day appointments, create a smart code in your dental record • Consider having the front desk code for this any time they

place a same day appointment on the schedule.

Tracking No-Shows and Late Cancellations

FOUR FUNDAMENTAL “BEST PRACTICES” THAT EVERY DENTAL PROGRAM SHOULD ADOPT:

1. Create a strong zero tolerance broken appointment policy with consequences that are clearly communicated to patients.

2. Enforce the policy consistently with no special exceptions from senior administration, providers or board members.

3. Educate patients about the value of their dental appointments and the importance of their keeping appointments.

4. Establish a culture of accountability for both patients and staff.

• Safety Net Dental Practice Management Series; Module 6: “Managing Chaos in the Dental Program” https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-practice-management-series

• HRSA guidance for no show policies: http://bphc.hrsa.gov/ftca/healthcenters/riskmanagementslides.pdf

• Medicaid guidance for charging for no shows: https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf

Helpful Links

https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-practice-management-series

















http://bphc.hrsa.gov/ftca/healthcenters/riskmanagementslides.pdf




https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf


















Exercise:

Determining the following practice metrics:

1. The Daily Demand for Emergency Care

2. The Emergency Rate

3. The Broken Appointment Rate

Fiscal year July 1, 2016- June 30, 2017:

o 5,378 patient visits

o 230 clinic days

o 920 emergency visits (as tracked by CDT D9110 and/or D0140 codes)

Case Study Bright Smiles Community Dental Clinic

To Calculate the Daily Demand for Emergency Care • Divide the total number of emergency visits (CDT codes

D0140 and D9110) by the total number of clinic days. Note: To ensure accuracy, one of these codes must be applied at

every emergency visit – including those when definitive care is provided (such as an extraction). o A $0 smart code could also be considered for billing purposes.

Measure: Description: Numerator: Denominator: Daily Demand for Emergency Care

Average number of emergency visits per clinic day during the reporting period.

Total number of emergencies (D0140, D9110, and/or ER smart code)

Total number of clinic days

Daily Demand for Emergency Care

Number of Clinic Days

Number of Emergencies

Average Daily Demand

Example 23 85 4

Month 1 #DIV/0!

Month 2 #DIV/0!

Month 3 #DIV/0!

Month 4 #DIV/0!

Month 5 #DIV/0!

Month 6 #DIV/0!

Month 7 #DIV/0!

Month 8 #DIV/0!

Month 9 #DIV/0!

Month 10 #DIV/0!

Month 11 #DIV/0!

Month 12 #DIV/0!

Annual #DIV/0!

SNS Daily Demand for Emergency Care Tracking Template

• Bright Smiles Community Dental Clinic’s daily demand for emergency care was about 4 visits/day

o 85 emergency visits ÷ 23 clinic days = 4 emergency visits/day

Daily Demand for Emergency Care Answer

Daily Demand for Emergency Care

Number of Clinic Days


Average Daily Demand

Example 23 85 4

• Divide the total number of emergency visits (CDT codes D0140 and D9110) by the total number of visits. Note: To ensure accuracy, one of these codes must be

applied at every emergency visit – including those when definitive care is provided (such as an extraction). o A $0 smart code could also be considered for billing purposes.

Measure: Description: Numerator: Denominator:

Emergency Rate

Percentage of overall patient visits that were emergency visits during the reporting period.

Total number of emergencies (D0140, D9110, and/or ER smart code)

Total number of visits

To Calculate the Emergency Rate

Emergency Rate


Number of Visits

Emergency Rate

Example 85 432 5% Month 1 #DIV/0!

Month 2 #DIV/0! Month 3 #DIV/0!





Month 12 #DIV/0!

Annual #DIV/0!

SNS Emergency Rate Tracking Template

• Bright Smiles Community Dental Clinic had an emergency rate of 5%

o 432 visits ÷ 85 emergencies = 5% emergency rate

Emergency Rate Answer

Emergency Rate


Number of Visits Emergency Rate

Example 85 432 5%

• Broken Appointment Rate = The percentage of all scheduled appointments that were broken appointments.

• To find this divide the sum of all no-shows and cancellations by the number of scheduled appointments

• First you must determine the number of scheduled (planned) appointments for the reporting period • Take the total number of actual patient visits • Add “no-show” appointments • Add last-minute cancellations • Subtract walk-ins/same day appointments

To Calculate the Broken Appointment Rate

Broken Appointments

Actual Visits No-Shows Cancellations Walk-Ins

Scheduled Appointments

Broken Appointment Rate

Example 300 50 35 70 315 27.0%

Month 1 0 #DIV/0!

Month 2 0 #DIV/0!

Month 3 0 #DIV/0!

Month 4 0 #DIV/0!

Month 5 0 #DIV/0!

Month 6 0 #DIV/0!

Month 7 0 #DIV/0!

Month 8 0 #DIV/0!

Month 9 0 #DIV/0!

Month 10 0 #DIV/0!

Month 11 0 #DIV/0!

Month 12 0 #DIV/0!

Annual 0 #DIV/0!

SNS Broken Appointment Tracking Template

Fiscal year July 1, 2016- June 30, 2017:

o 5,378 patient visits

o 1,216 no-shows

o 536 late cancellations

o 1,174 walk-in appointments

Case Study Bright Smiles Community Dental Clinic

Bright Smiles Community Dental Clinic has a broken appointment rate of 29%

o 5,378 + 1,216 + 536 = 7,130 – 1,174 = 5,956

o 1,216 + 536 = 1,752 visits (not including walk-ins)

o 1,752 ÷ 5,956 = 29%

The Calculation

Questions?

Break

Strategic Scheduling

211

Associate Vice President, Morton Hospital and Medical Center, 1992-2006

Publications Coordinator, Norwood Hospital, 1986-1992

Freelance Editor, 1982-1986

President, Board of Directors, Taunton Oral Health Center, 2008-present


Dori Bingham Program Manager, Safety Net Solutions DentaQuest Institute



Learning Objectives:

• Understand the basic elements of dental scheduling

• Understand how to use the schedule to maximize productivity for various provider types

• Understand options for scheduling of new adult patients

• Understand common schedule pitfalls and schedule busters

• Learn strategies for troubleshooting the scheduling process

Guiding Principles

The dental schedule should be used to achieve three key strategic objectives:

1. Improved oral health status for patients

2. Maximum access to care for patients

3. Financial viability of the dental program

Maximum Patient Access

• As a safety net dental provider, your mission should be to provide access to all disadvantaged patients who have difficulty getting care

• But special populations can be designated as priorities (eg, children, pregnant women)

• The daily schedule is an important tool in maximizing access to care

Maximizing Outcomes: Completion of Phase 1 Treatments • HRSA Definition of Phase 1 Treatment: diagnosis and

treatment planning, preventive services, emergency treatment, restorative treatment, basic (non-surgical) periodontal therapy, basic oral surgery, non-surgical endodontic therapy and space maintenance and tooth eruption guidance for children

• The daily schedule is an important tool for maximizing the number of patients whose Phase 1 treatment needs are completed

Financial Viability • Net revenue needs to be sufficient to meet total direct and

indirect expenses

• Net revenue includes patient care revenue plus any ongoing, predictable grants (such as 330 grants for FQHCs)

• The daily schedule is an important tool for ensuring the generation of sufficient revenue to at least cover direct and indirect expenses (and ideally generate a surplus)

Define the Scheduling Process

• How far out will appointments be scheduled?

• Only one appointment at a time (exception: procedures requiring more than one appointment to complete)

• Define how operatories will be used (how many per provider)

• Define appointment lengths for various procedures (use RVUs and time studies to establish times)

• Indicate where in each appointment type the dentist is needed vs. dental assistant time

• Indicate what types of appointments can be double-booked

The Schedule Process (cont.)

• Start and end times for appointments each day

• Who is authorized to schedule appointments

• Providers should always be working to the top of their licenses (eg, dentists being dentists, hygienists being hygienists)

• If expanded function dental assistants are available, they should also be working to the top of their abilities

Common Scheduling Pitfalls • Scheduling appointments out too far

• Scheduling multiple appointments for patients

• Putting too many new patients into the schedule

• Appointments that are too long (or not long enough)

• Not using provider time strategically

• Not being strategic about how and when to double-book

• Open time in the daily schedule (10 minutes here and there adds up!)

• Not being strategic about who can schedule appointments

Common Scheduling Pitfalls (cont.) • Hygiene appointments in the dentists’ schedules

• Not maximizing the potential of auxiliary staff with expanded functions

• Not identifying focus populations or using designated access to preserve appointments for focus populations

Defining Program Capacity

• Every dental program has a finite capacity

• Capacity depends on the number and type of staff, number of dental chairs and hours of operation

• Once we have defined our capacity, the schedule is the tool we use to maximize that capacity

• The schedule is also how we ensure that our capacity is utilized in a way that supports maximum access, outcomes and revenue

Focus Populations

• While FQHCs are required to provide access to care for all patients, it is acceptable to designate populations of focus that will have priority access to care, such as:

• Children

• Pregnant women

• Patients with chronic diseases such as diabetes, heart disease and HIV/AIDS

• The schedule is how we preserve access for focus populations

Designated Access

• The daily schedule ensures access for all patients

• But a certain number of appointments are reserved for patients belonging to focus populations

• These reserved appointments can’t be filled with other patient types until the day before

Phase 1 Treatment Completion

• Again, Phase 1 Treatment is treatment or procedures that lead to the “Elimination of dental disease.” • This includes: Oral cancer prevention and early diagnosis; prevention

education and services; emergency treatment; diagnostic services and treatment planning; restorative treatment; basic periodontal therapy (non surgical) and basic oral surgery that includes simple extractions.

• Why track this? • It is an important, HRSA recognized quality metric of the effectiveness

of your program. • A collective team focus on treatment completion helps to reduce the

delivery of urgent, episodic, fragmented care and fosters continuous coordinated care to your patients.

• Knowing how many Phase I treatment plans are completed in a given period (eg, each week) indicates how many new patients can be brought into the practice without interfering with the treatment of established patients.

Financial Goals

• Gross charges

• Net patient-generated revenue

• Bottom line (revenue after expenses)

• The schedule is an important tool for ensuring we meet our financial goals

Determining the Daily Revenue Goal

• Divide your total direct and indirect expenses by the number of clinic days per year (the number of days per week the clinic is open x 46 weeks)—that is the daily net revenue goal that must be achieved to break even

• For example: Total expenses = $950,000 5 days per week x 46 weeks = 230 clinic days per year $950,000 ÷ 230 = daily net revenue goal of $4,131

Scheduling Basics • Now that you’ve identified your practice goals, you’re ready to

start putting your scheduling plan together

• Identify your ideal patient mix (new patients, emergencies, focus populations, adults vs. children)

• Inventory your practice resources (providers, support staff, number of operatories, days/hours of operation)

• Identify hourly visit goals for each provider type (general dentists, specialists, residents/externs, hygienists, EFDAs)

• Define appropriate appointment lengths for various visit types (RVUs and work studies can help with this)

• Build and test the templates

• Use 10-minute increments if possible

Common Staffing Benchmarks

• General dentist, 2+ operatories, 2 assistants = 1.7 visits/hour

• General dentist, 1-2 operatories, 1 assistant = 1 visit/hour

• General dentist, 3+ operatories, 1 EFDA and 1-2 assistants = 2.5 visits/hour

• 4th year dental students = 0.5 visit/hour

• GPR Resident, Q1 = 1 visit/hour

• GPR Resident, Q2 = 1.2 visits/hour



• Hygienist, 1 operatory, unassisted = 1 visit/hour (typically, unless lots of kids)

• Hygienist, 2 operatories, assisted = 1.5 visits/hour

Scheduling for Dentists

• Minimum of two operatories and ideally two assistants

• Staggered appointments in two columns (possible use of 3rd column for overflow)

• For each standard visit (eg, restorative, emergent, extraction, crown prep, denture fabrication, etc.) define the workflow and indicate where and for how long the dentist is needed—create standard appointment blocks

• Line up the blocks so the dentist’s time is maximized—remember that he/she can’t be in two places at the same time!

• Consider each dentist’s individual characteristics in creating the template (age, experience, skill, etc.) but aim for standardization to the extent possible

Sample Template, Dentist Morning Schedule: Afternoon Schedule:

Time Op1 Op2Op3 (Overflow for

emergencies)

8:00 Emergency

8:10

8:20

8:30

8:40

8:50

9:00

9:10

9:20

9:30

9:40

9:50

10:00

10:10

10:20

10:30

10:40

10:50

11:00

11:10

11:20

11:30

11:40 Emergency

11:50 HOLD

12:00

12:10

12:20

12:30

12:40

12:50

Time Op1 Op2Op3 (Overflow for

emergencies)

1:00 Emergency

1:10

1:20

1:30

1:40

1:50

2:00

2:10

2:20

2:30

2:40

2:50

3:00

3:10

3:20

3:30

3:40

3:50

4:00

4:10

4:20

4:30

4:40 Emergency

4:50 HOLD

5:00

Intake 10-minute appointments for medical hx review, blood pressure, etc.

Operative

40-minute appointments for Fillings/extractions. Can expand to 60 minutes for more procedures

Anesthesia

First 10 minutes of operative appointment, if anesthesia is provided, where the dentist might be available for a brief side-booked appointment (eg, denture try-in, suture removal) or to provide a POE or LOE

Lunch 30 minutes

Color Code:

Scheduling for Hygienists • Easiest schedules to fill; hardest to KEEP full!

• Broken appointments in hygiene can wreak havoc

• Scheduling recall out 6 months generally not recommended

• Limiting new patients in the daily schedule may help reduce broken appointments

• Develop tasks for hygienists whose patients fail to show (eg, deploy to primary care? Work as assistants? Call patients due for recall? Confirm appointments? Help out at front desk?)

• Consider hiring one hygienist with a dedicated assistant rather than two hygienists—may actually reduce costs and improve productivity

Assisted Hygiene

• Requires two operatories and dedicated hygiene assistant

• Hygienist can see 1.5 patients/hour or 12-13 patients in an 8-hour day

• Assistant cleans and sets up operatories, seats/unseats patients, takes radiographs, assists with perio charting, takes blood pressures

• Eliminates RDH being dead in the water waiting for dentist to do exam—he/she moves on to patient in next operatory and assistant waits for dentist

• Still a need to rigorously manage risk of broken appointments AND need to assure demand for hygiene is there

Comparison: Unassisted vs Assisted Hygienists

Unassisted Hygienist Assisted Hygienist

Visits/hour 1 1.5

Visits/day 8 12-13

Visits/week (factors in 25% BA rate)

30 45

Revenue ($140/visit) $4,200 $6,300

Salary costs (includes 22% fringe)

$1,464 $2,149

Net revenue after salary $2,764 $4,151

Annual net revenue $127,144 $190,946

Sample Template, Assisted Hygiene Time Room 1 Room 2

8:00 greet, seat, update, BP (Patient 1)

8:10 x-rays

8:20 Prophy greet, seat, update, BP (Patient 2)

8:30 OHI review, disclose, anesth

8:40 OHI/dentist exam SRP (one quad)

8:50 Unseat patient/clean OP

9:00

9:10


9:30 Prophy Unseat patient/clean OP

9:40


10:00 Unseat patient/clean OP Prophy

10:10


10:30 x-rays

10:40 Prophy OHI/dentist exam


11:00 Greet, seat, update, BP (Patient 6)

11:10 OHI/dentist exam Prophy


11:30 Greet, seat, update (Patient 7)

11:40 Sealants x 4 OHI/dentist exam



The Result: 7 patients in 4 hours! Patients have the same amount of time in the dental chair, the work is just redistributed to provide more access.

Unassisted Hygienist AM and PM Schedule

8:00 AM Sealants 1:00 PM

8:30 AM Child recall 1:30 PM

9:00 AM

New Patient

Child 2:00 PM

New Patient

Child

9:30 AM Child recall 2:30 PM

10:00 AM 3:00 PM

10:30 AM 3:30 PM

11:00 AM 4:00 PM

11:30 AM 4:30 PM

12:00 PM 5:00 PM Sealants

Morning Schedule Afternoon Schedule

Adult Recall

New Patient

Adult

New Patient

Adult

Scaling and

Root Planing

Adult Recall

Scheduling Adult New Patient Visits: Reasons for Not Breaking Visits Up

• Routine unbundling can be a red flag for Medicaid utilization review/potential audit/takebacks and penalties

• Some patients are irked at needing two visits

• Extra visits clog up the schedule, making it even harder to complete treatment on existing patients in a timely manner

Two Possible Scenarios Scenario A:

Unable to Do Comp Exam due

to Heavy Calculus/Plaque

Visit 1: D0210 (FMX) and either D1110 (prophy) or D4355 (full mouth debridement)

Visit 2: D0150 (comp exam) and either PSR or full perio charting (likely needed)

Scenario B:

Able to Do Comp Exam

Visit 1: D0210 (FMX), D0150 (comp exam) and D1110 (plus PSR or full perio charting)

Rationale for Breaking Up Visits

• Many patients haven’t been to a dentist in years (if ever) and have poor oral hygiene

• Need to separate the exam and prophy because we don’t know what kind of prophy will be needed (ie, prophy or debridement)

• Dentist can’t do the comp exam until all the calculus is removed (although in many practices, the first visit is the comp exam, followed by the prophy visit)

• Not enough time in the visit for the comp exam, perio charting, x-rays and prophy—don’t want to create extra long appointments because of the risk of broken appointments

Recommendations • Consider putting all new adults in the hygienist’s column for 60

minutes—hygienist follows protocol for Scenarios A or B depending on how patient presents

• Develop a protocol (and state in policy format) that the goal of the new adult patient visit is to do as much as possible in the time allotted (eg, exam, x-rays, perio charting and cleaning) but that care may need to be extended over two visits for patients with heavy calculus

• Document in the patient’s chart why the patient needs to be brought back for a separate exam visit with the dentist

• Exam visits with the dentist can be 30-minute visits in the overflow chair

• Reasonable to screen through the PSR first and then complete a comprehensive periodontal exam if indicated

• Pilot, test and tweak as necessary

Document the Scheduling Process

• Create a formal scheduling policy

• Include scheduling templates as attachments

• Review the policy with entire staff

• Make sure staff responsible for scheduling know how to use the templates

• Monitor the process closely, provide immediate feedback when staff deviate from the process and tweak the templates as needed to ensure attainment of strategic goals

Schedule Busters

• Patients who cancel at the last minute • Patients who don’t show up or show up late • Double- or triple-booked patients who all show up

unexpectedly • Too many emergencies/walk-ins worked into the daily

schedule • Too many new patients in the daily schedule • Too many patients altogether in the daily schedule • Logjams at check-in or out • Providers who fall behind (or the entire practice falls behind) • Not enough support staff (assistants and

reception/registration)

Schedule Busters (cont.)

• Patients put in wrong appointment slots (eg, hygiene patient in dentist’s column; single restoration put in crown prep slot; multiple filling appointment put in short-procedure slot)

• Appointments that are too short (or too long)

• Lack of instruments/staff to keep up with sterilization

• Technology issues (computers slow, freeze up, bounce staff out, breakdowns, etc.)

• Providers and assistants bogged down with paperwork (referrals, pre-treatment authorizations, prior authorization requests, etc.)

Strategies for Resolving Schedule Busters

• Implement strategies for reducing broken appointments (topic for another presentation!)

• Be strategic with double-booking • Develop a strategy for managing emergencies/walk-

ins • Consider limiting number of new patients (eg, one to

two per day in each hygienist’s schedule, priority given to focus populations)

Strategies for Resolving Schedule Busters cont.

• Recalculate your maximum visit capacity each day and compare against number of actual appointments being scheduled (are you overscheduling?)

• Logjams at check-in/out • Flow-chart these processes

• Root cause analysis—why is this happening? • Develop and test strategies to improve patient flow (re-

engineer tasks, redesign physical space, address staffing issues, etc.)

Strategies (cont.)

• Providers running late/practice falling behind • Root cause analysis-why is this happening?

• Develop and test strategies to stay on time (reconfigure operatory assignments, availability of support staff, scheduling tweaks, seating and preparing patients, workflow around x-rays, etc.)

• Scheduling errors

• Root cause analysis—why is this happening?

• Review scheduling process with current staff

• Provide additional training if necessary

• Review frequently to enhance accountability

Strategies (cont.)

• Lack of instruments/staff to keep up with sterilization • Root cause analysis-is the issue that we need more instruments or

more staff? In either case, financial investment is generally more than offset by smoother operations and improved provider productivity

• Technology issues • Root cause analysis—why is this happening?

• Are we behind in upgrading our EDR/PMS? Do we need to upgrade hard drives/servers? Do we need to consider an alternative system?

• Too much paperwork in the hands of providers/assistants • Work flow analysis to determine what work needs to be done and

who is/are best people to be doing this work

Questions?

Lunch

Staffing For Success

Choosing Best Staffing Models

• Identify program resources

• Know your capacity

• Review your state Practice Act

• Providers should work to the top of their licenses

• Hire for attitude first, skill second

Employer Responsibility to Staff

• Job description

• Performance evaluations

• Annual or semi annual reviews

• Raises or compensation

• Foster accountability and buy-in

• Listen carefully

• Ask for input

Staff Responsibility to Employer

• Do Your Job!

• Respect other employees

• Follow protocol

• Follow policys of the dental office

• Report breech in protocol immediately

Staff Compensation • Be competitive to get the best people

• Factor in cost of employee benefits—make sure staff know the monetary value of the benefits they receive

• Hire good people and pay them a competitive salary so they will stay

• Turn over has hidden costs

You get what you pay for!

Benefit Tracker – Salaried Employee

Tool created by Dr. Janet Bozzone, Open Door Family Medical Center, NY

Benefit Tracker – Independent Contractor

2013 Dental Directors Average Salaries- NNOHA

Dental Directors

2013 Average Salaries- NNOHA

over $140K 40%

Between $140K - $125K 30%

Between $125 - $110K 16%

Between $110K - $95K 11%

Less than $95K 3%

Source: Presentation by Ken Bolin, DDS, MPH, Associated Professor and Graduate Program Director, Department of Public Health Sciences, Baylor College of Dentistry

www.nnoha.org

2013 Hygienists Average Salaries – NNOHA

www.nnoha.org

Source: Presentation by Ken Bolin, DDS, MPH, Associated Professor and Graduate Program Director, Department of Public Health Sciences, Baylor College of Dentistry

Hygienists

2013 Average Salaries- NNOHA

over $70K 20%

Between $70K - $60K 20%

Between $60 - $50K 40%

Between $50K - $40K 15%

Less than $40K 5%

Bureau of Labor Statistics Annual Mean Wages as of May 2016: Top States Dentists Mean Wage

Delaware $236K

North Carolina $236K

Alaska $234K

New Hampshire $220K

Nevada $210K

Hygienists Mean Wage

Alaska $103K

California $95K

New Mexico $91K

Washington $90K

Nevada $87K

Dental Assistants Mean Wage

Minnesota $47K

New Hampshire $46K

Alaska $45K

DC $45K

Massachusetts $44K

https://www.bls.gov/oes/current/oes291021.htm

2016 Average Salaries – Salary.com 2016 – Salary.com

Dental Directors $147,361

Staff Dentist $125,882

Hygienists $ 70,425

Dental Assistants $35,621

Practice Manager $67,225

Clerical/Receptionists $33,588

Salaries vary based on location, number of dental sites/programs, experience, hours worked, etc. and therefore research needs to be done to reflect true salary ranges for your program/area.

www.salary.com

Difference Between Bonus and Incentive Plans

• A Bonus is given after a task has been successfully completed; an incentive is offered to stimulate completion of a task

• Both incentives and bonuses occur AFTER financial viability is achieved

• Both are determined by revenue not charges

Incentive Programs

• Variety of incentive options including: • Incentive programs for providers

• Bonus programs for providers & staff

• Well defined with objective standards to evaluate performance & how their work is contributing to the mission & goals of the program • Frequency (monthly, quarterly – rather than annually)

• Based on target goals that directly influence the program’s income, and are achievable

• Needs to be simple, easy to understand & manage

Dental Program Models

• Dental Director • DD is the Clinical Director, Practice Manager and Provider!

• DD as Clinical Director and Provider • Oral Health Practice Manger provides oversight &

management of operations

• Practice Manager • Ideally, the Dental Director and Practice Manager work

together as a cohesive team to lead the dental program • DD provides the clinical oversight

• PM provides the operational oversight

Using Accurate, Meaningful, Timely Data to:

• Set Productivity Goals: Access, Quality, Outcomes & Finance • Monitor & Manage Financial Viability • Develop a Dental Program Budget & Allocate Resources

• Executing a Continuous Quality Improvement System

• Defining Clinical Scope of Project & Service • Oversight of the Policies and Procedures • Serving as a Member of the Health Center Continuous Quality

Improvement Team • Participate in Senior Administration Management Meetings &

Discussions

DD Responsibilities Include:

• Developing and Updating Policies & Procedures

• Establishing scheduling & patient flow guidelines

• Customer service & patient satisfaction surveys

• Coordinating Staff Recruitment, Development & Training

• Resolving conflict

• Creating a culture of accountability

DD Responsibilities cont.

Administrative vs Clinical Time for Dental Directors • DDs need to balance both clinical and

administrative responsibilities

• No standard benchmark for administrative time

• Dependent on # of operatories, # of clinics, # of staff, etc.

• There should be a set of deliverables accomplished by DDs and PMs during administrative time

Executive Leadership Responsibility to Dental Director • Create job description that clearly defines

expectations

• Include the time necessary to take advantage of opportunities for continuing education and trainings

• NNOHA Conference

• PCA Trainings

• State & Local Dental Association Meetings

Hygienists Roles and Responsibilities

• Clinical duties – chart notes, clean and stock operatory, patient care

ALSO: • Run reports

• Treatment plans

• Recall

• Overdue recall

• Call patients to schedule overdue prophy appointments and unscheduled treatment plans

• Turn over dentist operatories

• Sterilization

Key Dental Program Staff

• Reception/Registration Team • Hire at least one reception/registration team member for every

5,000 patient visits

• The front desk is the public face of the clinic

• Front desk tends to have high turnover

• These tend to be the lowest paid positions

• These tend to be IMPORTANT positions

• Billing • In house is best practice

• Should have dental experience

Credentialing and Privileging

Credentialing* • Credentialing: The process of assessing and

confirming the qualifications of a licensed or certified health care practitioner.

• HR Responsibility but DD and PM should be aware of the process

• This is a criteria for FTCA (Federal Tort and Claims Act)

• In order to be covered your providers must be credentialed.

https://bphc.hrsa.gov/programrequirements/pdf/healthcentercompliancemanual.pdf

*Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16 -2002-22

Privileging* Privileging/Competency: The process of authorizing a licensed or certified health care practitioner’s specific scope & content of patient care services. This is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.

• The DD creates the privileging policy and tool

• Clinical privileges are determined by a review of the provider’s licensure, experience, and training as set forth in the policy.

• Privileging is done at the initial hiring of the provider; on an annual review basis and on an as needed basis if questions of clinical competence arise.

• FTCA mandatory

*Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16 -2002-22

https://bphc.hrsa.gov/programrequirements/pdf/healthcentercompliancemanual.pdf

Reporting Structure

Reporting Structure

• Best model: DD reports directly to the CEO • Allows for better communication & ownership of the

program

• Care & business models of medical & dental are so different that both the DD & CMO/MD can become frustrated

• Allows for quarterly meetings with the CFO directly related to budget and profit and loss

DDs who report to the CMO/MD are two times more likely to leave the HC than those who report directly to the CEO

www.nnoha.org

www.nnoha.org – Operations Manual, Health Center Fundamentals Chapter 1, page 15

Training/Orientation

• Develop a formal orientation program for new staff to ensure they are properly trained

• Include job shadowing

• Create checklists, scripting & other materials to help guide staff

• Regularly update new & existing staff on use of the EDR/PMS

• Do periodic reviews of key operations

• Offer continuous training & opportunities outside the clinic

Continuing Ed (CE) and Training

• Allowing for quality CE & training is beneficial • Ensures patients are receiving the most recent standards of care

• Allows providers to continue their professional development – necessary for provider satisfaction & continued licensure

• Opportunities to share evidence-based practices & models, lessons learned & resolution to relevant issues

• Have a budget for travel & conference registration as part of their benefits package • Reduces feelings of isolation while offering support & camaraderie

• Variety of opportunities exist online, webinars, PCA events, DD work group, state or local health departments

Fostering Team Work and Accountability

• Consider morning huddles for the entire dental staff – both front desk & clinical staff together

• Regular monthly staff meetings – include a review of program performance • Block out the patient schedule, not over lunch

• Take & share meeting minutes with staff who can’t attend

• Have an agenda for every meeting • Don’t just meet to meet, have a purpose

• Include the dental team in all staff meetings • Dental often feels forgotten

• Medical/dental meetings – work as a team to treat the whole person

• Include Dental in CQI

Creating Accountability Effective Leadership Skills

• Don’t ignore poor performance

– It must be addressed immediately and consistently, or you will lose all credibility and destroy your team’s morale

• Coach in private, recognize publicly

• But don’t focus only on poor performance!

• Instead “catch” your staff when they do something good!

• Praise, praise, praise!

What do staff want?

• They want to feel valued

• They want to feel part of the team

• They want to feel confidence in the capabilities of their leadership

• They want reasonable, supportive leadership who have integrity and will treat everyone fairly and consistently

Questions?

Creating An Improvement Plan for Success

The Improvement Plan (IP)

Recipe to a Successful IP

• Identify and state the Problem or Problems

• Apply Strategies to address each of the problems

• Define the Actions Steps to execute each strategy

• Assign a Person or Persons responsible

• Attach Due Dates

• Set goals and performance Metrics

Step 1: Identify the Problem

What are the problems that are negatively impacting…

• Patients

• Staff

• Outcomes

• Quality of care

• Financial sustainability

• Access

Step 1: Identify the Problem, Cont.

• The broken appointment rate is 40%

• Providers are working late and somedays do not get a lunch break

• High number of walk-ins and emergencies

• Patients have been complaining about the long waits

• Providers feel burnt out

• Patients cannot schedule an appointment for at least another 3 months

Step 1: State the Problem

• The broken appointment rate is 30%

• No-shows and last-minute cancelations are negatively impacting access to care and productivity. The policy is not consistently enforced.

– By reducing the broken appointmnet rate the practice can increase revenue and decrease chaos and stress for dental staff. A major impact will be an increase in the percentage of patients who complete their phase 1 treatment within 12 months.

Step 2: Identify Strategies

• Revise and distribute a strong, no-tolerance Broken Appointment policy to establish accountability with the patient and staff. Post signs prominently within the practice explaining the policy.

• Flag patient charts of those who breach the policy and send letters reminding those patients of the policy they agreed to abide by.

Step 3: Create Action Steps

1. Revise the current policy

2. Obtain Board approval

3. Educate staff and patients about the new policy

4. Require all new patients to sign the policy

5. Monitor the BA rate and access policy after 3 months

Step 4: Assign Due Dates & Responsibilities

Action Steps Due Date Person(s) Responsible

Revise the current policy

6/30/17 Dental Director and Practice Manager

Obtain Board approval

7/15/17 Dental Director and CEO

Educate staff and patients about the new 8/1/17 All staff

Require all new patients to sign 8/30/17 Front Desk

Monitor the BA rate and access policy after 3 months and report to leadership

Ongoing Practice Manager

Step 5: Set a Target Goal for the Metric

Current BA rate = 40%

Year 1: 20%

Year 2: 15%

Every quarter the broken appointment will be monitored to ensure:

• Policy is effective

• Everyone is consistent with enforcing the policy

• BAs are being documented accurately

Step 6: Execute and Monitor Results

• Create Buy-In and Accountability among staff

• Collect data to monitor result; have a measurable goal for everything!

• Regular meetings to discuss the progress in executing the actions steps

• Discuss barriers that arise

• Brainstorm ways to overcome barriers as a team

• Celebrate successes

• Recognize and award staff

• Coach and offer feedback when there are setbacks

Common Issues

• Provider Productivity

• No-Shows/Last-Minute Cancellations

• Insufficient Support Staff

• Leadership Issues

• Other Staffing Issues

• Scheduling Issues

• Emergencies

• New Patients

• Huge Demand for Care (but sometimes lack of demand)

• Communication Issues

• Fee Schedules/Sliding Fee Scales

• Churning/Unbundling

• Billing/Collections Issues

• Payer Mix Issues

• Lack of Medical/Dental Integration

• Lack of Formal Quality Management Program

• Clinical Issues

• Not Enough Children to Subsidize Uninsured Adults

Resources

• Improvement plan template

• Best Practice Manual

• Tools to create goals

• Sample policies

• DQI Resource Library

• Online Learning Modules

Exercise

Utilizing the Best Practice Manual and Improvement Plan Template

1. Download the Best Practice Manual (pdf)

2. Download the Improvement Plan Template (Word)

3. Identify 3 areas for improvement that your clinic can work on in the short term (next 3 months)

4. Decide on at least 1 strategy for each area

5. Create actions steps for each strategy

Closing/Wrap-Up & Post Training Evaluation

Post-Training Evaluation • https://www.surveymonkey.com/r/BCBS17Post

https://www.surveymonkey.com/r/BCBS17Post




SNS Technical Assistance Resources • Dental Policy & Procedure

Manual Template

• Sample Clinical Protocols

• Sample Dental Job Descriptions

• Sample Broken Appointment Policies

• Scripting for CHC Dental Staff

• Profit & Loss Budget Variance Tool

• Financial and Productivity Goals Tool

• Payer Mix Projection Tool

• Dental Program Performance Tracking Tool

• Productivity Benchmark Guide

• Sample Scheduling Policy

• Sample Emergency Policy

• Sample Quality Assurance Policy

• And much, much more!

SNS Online Practice Management Series

• Developing Billing Excellence • Fee Schedules, Sliding Fee Scales, & Management of the Self-

Pay Patient • Safety Net Dental Program Finance and Productivity: Your

Mission and Your Margins • Front Desk Customer Service • The Front Desk: Creating Your Dream Team • Managing Chaos in the Dental Program • Scheduling by Design https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-practice-management-series

FREE CEUs Available!



















Special Topic Series • Payment Reform in Oral Health Care! • Interprofessional Practice • ECC Management for the General Dentist • Potty Mouth

https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/dentaquest-special-topics-series

FREE CEUs Available!















Partnering to Strengthen and Preserve

the Oral Health Safety Net

Documents

Your Oral Health Program: Strategies for Success · Your Oral Health Program: Strategies for Success BCBS Foundation Training December 1 & 2, 2017 . Preparation ... /year with 1100