JEFFERSON COUNTY PUBLIC HEALTH

Integrating Cavity Prevention with WIC Nutrition Services

Replication Manual

I N T E G R A T I N G C A V I T Y P R E V E N T I O N W I T H W I C N U T R I T I O N S E R V I C E S

Replication Manual

Prepared by: Melissa Broudy, RN, BSN, BA

Under supervision of:

Susan Moyer, RN, MSN, CNSPH

Jefferson County Public Health 1801 19th Street

Golden, CO 80401 Phone 303.271.5700 • Fax 303.271.5702

With special thanks to:

Cavity Free at Three Team Members Linda Reiner, MPH

Diane Brunsen, RDH, MPH Dr. Denis Lewis, DDS

Made possible by grant award from: Cavity Free at Three,

a three-year, statewide effort to prevent oral disease in young children. The effort aims to engage dentists, physicians, nurses, dental hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant

women, infants and toddlers.

The project is jointly funded by: Caring for Colorado Foundation, The Colorado Health Foundation, The Colorado Trust, Delta Dental of Colorado Foundation, Kaiser Permanente and Rose Community Foundation and implemented in partnership with the

University of Colorado Denver School of Medicine, Department of Family Medicine and the University of Colorado Denver School of Dental Medicine.

Table of ContentsOverview ................................................................................... 1 Why cavity prevention is good public health ............................. 1

Cavity Free at Three ....................................................................... 1 Prevalence in Colorado................................................................... 1 Jefferson County Public Health WIC Clinics ................................... 2 Public Health Cost of Dental Caries................................................ 2

Removing client barriers to preventive care .............................. 3 Maslow’s Hierarchy of Needs.......................................................... 3 Time Costs...................................................................................... 3 Financial Costs ............................................................................... 4 Travel Costs.................................................................................... 4

Delivering a public health cavity prevention model ................... 4 Oral Health Promotion Meets Existing Public Health Infrastructure 4 Staff and Contractor Training in the Infant Oral Health Model......... 5 Developing Local Referral Resources............................................. 5

Independent dental hygienists provide financial sustainability .. 6 Colorado Practice Law for Registered Dental Hygienists................ 6 Recruiting independent RDHs......................................................... 7 Establishing a No-Cost Contract with Incentives Sufficient to Attract and Retain RDHs ............................................................................ 7 Immunization Requirements ........................................................... 7 Work Space .................................................................................... 8 Supplies .......................................................................................... 8 Flexible RDH Schedules ................................................................. 9 Managing Client Flow...................................................................... 9 Orienting RDHs............................................................................. 10 Orienting WIC Staff ....................................................................... 10 Pathways for Ongoing Communication ......................................... 10

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Overview Dental disease is the number one chronic disease of children in America, yet, it is a preventable disease.

efferson County Public Health (JCPH) has teamed up with the Cavity Free at Three Technical Assistance Team, WIC staff, and independent Registered Dental Hygienists (RDHs) to prevent cavities in pregnant women and children ages 0-5. JCPH has contracted with three independent RDHs to deliver the Cavity Free at Three infant oral health model to WIC clients as they attend appointments. This

model’s success is founded in (1) removing client barriers to care, (2) delivering a proven public health model for cavity prevention, and (3) achieving financial sustainability by contracting with independent dental hygienists who are Medicaid Providers to deliver the model’s services at no cost to the county. After only three months of implementation, over 500 WIC clients have undergone (1) oral health assessment by a Registered Dental Hygienist, (2) anticipatory guidance to enhance oral hygiene behaviors, and (3) fluoride varnish treatment. This model offers impressive public health bang for its buck and can be easily replicated in other WIC programs throughout Colorado.

Why cavity prevention is good public health Cavity Free at Three Cavity Free at Three is a three-year, statewide effort to prevent oral disease in young children. The effort aims to engage dentists, physicians, nurses, dental hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant women, infants and toddlers.

Our goal is simple: We want all children in our state to be cavity free by the time they reach age three.

Prevalence in Colorado Dental caries is the most common chronic childhood disease; 5 times as common as asthma; 7 times as common as hay fever. Eighty percent of the disease is in twenty percent of the population. It is largely a disease of poverty. Dental disease affects children's ability to eat properly, grow, attend school and learn.

In Colorado the problem is profound,

• 18% of 2-4 year olds have dental caries; 16% have untreated decay.

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• 45.7% of kindergarteners have dental caries; 26.9% have untreated decay.

• 57.2% of third graders have dental caries; 26.1% have untreated decay.

• By age 17, 78% of children have had at least one cavity; 7% have lost a permanent tooth to dental decay.

Jefferson County Public Health WIC Clinics WIC’s mission to safeguard the health of low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. Established as a pilot program in 1972 and made permanent in 1974, WIC is administered at the Federal level by the Food and Nutrition Service of the U.S. Department of Agriculture. WIC is not an entitlement program as Congress does not set aside funds to allow every eligible individual to participate in the program. WIC is a Federal grant program for which Congress authorizes a specific amount of funds each year for the program.

The following benefits are provided to WIC participants:

• Supplemental nutritious foods

• Nutrition education and counseling at WIC clinics

• Screening and referrals to other health, welfare and social services

WIC is effective in improving the health of pregnant women, new mothers, and their infants. A 1990 study showed that women who participated in the program during their pregnancies had lower Medicaid costs for themselves and their babies than did women who did not participate. WIC participation was also linked with longer gestation periods, higher birth weights and lower infant mortality.

JCPH houses WIC clinics at three locations throughout the county where low-income clients who are pregnant and/or have children ages 0-5 attend scheduled nutrition counseling appointments and pick up checks to buy food every three months. Attending these appointments is a high priority for clients because it immediately results in meeting the family’s basic need for food.

Public Health Cost of Dental Caries Once established, dental caries requires treatment. A cavity only grows larger and more expensive to repair the longer it remains untreated. Fewer than 1 in 5 Medicaid-covered children received at least one preventive dental service in a recent year; many states provide only emergency dental services to Medicaid-eligible adults.

Poor children have nearly 12 times more restricted-activity days because of dental-related illness than children from higher-income families. Pain and suffering due to untreated tooth decay can lead to problems in eating, speaking, and attending to

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learning. Many adults also have untreated dental caries (e.g., 27% of those 35 to 44 years old and 30% of those 65 years and older).

Removing client barriers to preventive care Living near or below the poverty line while pregnant and/or caretaking for young children not yet in school poses several barriers to preventive dental care.

Maslow’s Hierarchy of Needs Maslow's hierarchy of needs assigns priorities to five different categories of needs common amongst people. It is often depicted as a pyramid consisting of five levels: the first lower level is associated with physiological needs, while the top levels are termed growth needs associated with psychological needs. Deficiency needs must be met first. The higher needs in this hierarchy only come into focus when the lower needs in the pyramid are met.

Poverty forces people to spend much of their time and energy in pursuit of meeting basic physical and safety needs. Nutrition, a key physical need at the base of Maslow’s Hierarchy, is met through WIC program participation. This serves as a helpful framework for understanding why WIC clients have much higher attendance rates for WIC appointments than they do for preventive dental care appointments.

The time, money, and travel it takes to obtain preventive dental services are often too great for WIC clients because those resources are needed to meet basic needs. The JCPH model for cavity prevention service delivery enables participation by minimizing the opportunity costs WIC clients pay to obtain preventive dental services.

Time Costs Time spent finding a provider, making an appointment, arranging transportation, and attending an appointment on time are significant to low-income families with small children. This process would take an estimated 4-6 hours normally, but is reduced to 15-20 minutes in the JCPH model.

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Financial Costs Low-income families often have difficulty paying for food and housing, and cannot divert resources from meeting those needs in order to obtain preventive dental care. Often, a dental professional is not seen until the basic need to relieve physical pain resulting from advanced cavities or associated accesses becomes a priority. The poorer a person is, the more pain they will endure before seeking treatment. Further complicating a low-income client’s decision making process is that once a condition is serious enough to cause pain, it usually only gets more expensive to treat as time progresses.

The JCPH model eliminates costs of preventive treatment, as no clients are charged any out-of-pocket expenses. Further, treatment costs are facilitated by referring clients to local dentists who work with low-income clients by accepting Medicaid, CHP+, and/or participate in reduced fees and payment plans.

Travel Costs The cost of owning and driving a car, taking a bus, or asking a friend to drive you to and from an appointment are usually only spent on high-priority appointments meeting basic needs amongst low-income families with children.

Travel costs are eliminated in the JCPH model by seeing clients for preventive oral health care after their high-priority WIC appointment in the same place with no separate appointment needed.

Delivering a public health cavity prevention model Oral Health Promotion Meets Existing Public Health Infrastructure Jefferson County Public Health was one of ten communities to receive the first round of Cavity Free at Three grants in 2008. Over 200 physicians, dentists, nurses and registered dental hygienists were trained in the program, including 35 public health nurses and contracting registered dental hygienists at JCPH. Caring for Colorado Foundation, The Colorado Health Foundation, The Colorado Trust, Delta Dental of Colorado Foundation, Kaiser Permanente and Rose Community Foundation are jointly funding Cavity Free at Three.

JCPH received funding, educational materials, clinical supplies and technical assistance to implement the infant oral care protocol. Each grant included:

• $10, 000 for program funding

• On-site training and ongoing technical assistance on the infant oral care model

• Help in developing systems for infant oral care

“It’s so fast and easy, I feel like I’ve done something great for my child that I might not have been able to do if I had to pay or make a separate appointment.” –WIC Client

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• Provider and patient information and education

• 500 infant oral care kits for the infant oral care exam

Staff and Contractor Training in the Infant Oral Health Model The Cavity Free at Three Technical Assistance Team provided an onsite eight hour technical assistance training for JCDHE public health nurses (PHN), supervisor for the Women Infant and Children (WIC) program and local independent Dental Hygienists.

Training included:

1. Methods to incorporate an oral health risk assessment, parent education and fluoride applications for young children into their services.

2. Methods to address the oral health needs of pregnant women and provide them with extra education about how to care for their infant’s teeth.

3. Demonstration and hands on practice in completing oral hygiene screenings and applying fluoride as needed to JCDHE clients 0-5 years.

Delivering the Infant Oral Health Model Jefferson County Public Health developed a service delivery model ideal for its clients and staff. The diagram below illustrates the relationship between the Cavity Free at Three infant oral health clinical model and the JCPH service delivery model developed for our county public health environment.

Developing Local Referral Resources Timely and appropriate referrals to dental care are essential to dental health and require work at the local level. JCPH seeks to maximize clients’ oral health by facilitating

JCPH CHS Staff

CF3 Service

Providers

JCPH EPSDT

Insurance Providers

Local Dental Home

JCPH WIC Staff

Target Population Program

Coordinator

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establishment of a dental home and referring to dentists for caries treatment as early in the disease process as possible.

Low-income clients who have Medicaid insurance or no insurance often need guidance in finding providers who will welcome them. To solve this problem, a JCPH public health nurse conducted targeted outreach visits to community dental service providers who see children age 0-5 years, accept Medicaid and/or offer discounted or payment plans for the uninsured. These providers became part of a referral list of community dental service providers given to all Cavity Free at Three clients.

Steps to Developing Referral Resources

1. Call all area Medicaid Providers who see children as young as 12 months old.

2. Conduct Outreach Education Visits with all identified providers to teach about the Cavity Free at Three Model and how it will be used with WIC clients.

3. Ask for permission to add dental service provider to referral list.

4. List payment options for each provider on list, such as Medicaid, CHP+, discounts, and payment plans.

5. Invite dental service providers and office representatives to participate in the education portion of the Cavity Free at Three Technical Assistance Training Course.

6. Establish Emergency Referral Protocol with at least one dental service provider.

7. Update Referral List on a quarterly basis.

Independent dental hygienists provide high quality of care and financial sustainability Colorado Practice Law for Registered Dental Hygienists Until 1986, all state practice acts mandated some level of dental supervision for dental hygiene practice and most required that dental hygienists be employed by dentists. In 1986, the Colorado state legislature revised the Dental Practice Law (Colorado DPL) to permit dental hygienists to practice either supervised or unsupervised. The revised law also permitted a dental hygienist to be the "proprietor of a place where supervised or unsupervised dental hygiene is performed and may purchase, own, or lease equipment

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necessary to perform supervised or unsupervised dental hygiene" and authorized specific services for supervised and unsupervised dental hygiene practice.

Recruiting independent RDHs Colorado RDHs can bill Medicaid independently as part of their own dental hygiene practice. A list of RDHs in the local area who have a Medicaid ID number and own their own practice were called to be screened for participation. Another RDH was identified via outreach visits with local dental offices who serve low-income children. All RDHs were enthusiastic about obtaining such convenient and reliable access to the WIC population and met the following qualifications: (1) be a Registered Dental Hygienists in the State of Colorado, (2) be a Medicaid Provider, and (3) Have the knowledge and ability to bill Medicaid/Insurance companies as part of an independent practice not related to JCPH.

Three qualified RDHs were identified and invited to attend the Cavity Free at Three Training in the infant preventive oral care model.

Establishing a No-Cost Contract with Incentives Sufficient to Attract and Retain RDHs JCPH developed a no-cost contract to enter into with independent dental hygienists for the implementation of this model. The following stipulations and incentives were outlined:

• JCPH will provide RDHs with exam space adjacent to WIC clinic waiting rooms at no cost. Arvada and Lakewood branches of WIC clinics see between 50 and 125 clients per day.

• RDHs will provide infant oral health model to all WIC clients whether or not they have insurance, and can bill Medicaid for those clients who are eligible for reimbursement.

• RDHs will administer only those services contained in the Cavity Free at Three infant oral health model.

• Cavity Free at Three education materials and supplies will be provided by JCPH until the 1,000 packets provided by the donor are used up.

• JCPH is not responsible for any billing or possible malpractice resultant from RDH services provided.

Immunization Requirements RDHs were required to meet the same immunization requirements as JCPH staff at their own expense. Costs incurred by the RDHs ranged from $50 to $150, placing more of a barrier to entry than anticipated. If possible, it is recommended that JCPH absorb the cost of meeting immunization requirements as it does for its non-contract employees.

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Work Space Existing infrastructure of clinic exam rooms adjacent to WIC waiting areas offers a unique opportunity to conveniently locate RDHs in close proximity to WIC clientele. JCPH usually has at least one unused exam room per day, and the RDH uses left-over exam rooms, varying according to day, in order not to disrupt clinic operations.

Supplies Cavity Free at Three provided 1,000 kits to perform the infant oral health model, which the RDHs divided amongst them until supplies ran out. Education materials were also shared.

In order to obtain supplies after grant materials were exhausted, the following steps were taken:

• Met with Diane Brunson to determine how much JCPH could reduce the cost of the $6.18 packet developed by Cavity Free at Three while maintaining comparable standard of care. Determinations are detailed in table below.

• Obtained educational material design files to reproduce in-house at low cost.

• Used JCPH funds to supply RDHs with masks, gloves, and chucks for exams. (pending approval)

Cavity Free at Three Pre-Packaged Kits

1,000 Supplied by Cavity Free at Three

Sustainability Supplies Allowing Comparable Quality of Care

DuraShield 5% Sodium Fluoride Varnish, Bubble Fun Flavor w/Xylitol,

individually packaged with disposable brush

5% Sodium Fluoride Varnish in Tube, amount to be titrated to clients’ needs.

($0.50-0.75/dose)

24 gram tube of Kids Crest Toothpaste Large tube of ADA approved toothpaste, amount to be titrated to client’s needs.

($0.25-0.50/dose) Disposable oral exam mirror Reusable sterilized exam mirrors

(negligible) Four pieces of gauze Bulk gauze to be used as needed

(negligible) Children’s toothbrush Children’s toothbrush used only for child

clients ($1.00-2.00/client) Parent’s toothbrush Adult’s toothbrush used only for pregnant

clients ($1.00-2.00/client) Total: $6.18 Total: $2.00-$3.00

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Flexible RDH Schedules RDHs required flexible schedules due to the need to give private practice clients scheduling priority. Each RDH came in one to three days per week when the program began, and eventually settled into a somewhat regular schedule. Strict RDH schedules did not make sense, as their services were volunteer. The emphasis was placed on establishing a positive work experience and allowing for as much Medicaid compensation as possible while seeing all clients regardless of insurance status.

The following guidelines for WIC staff were developed to facilitate flexible RDH schedules:

• Because the dental hygienists’ schedules need to remain flexible, they will set up their promotional cart in the waiting area and notify WIC staff when they are available to see clients. Referring WIC clients to the RDH is encouraged at these times.

• Please refrain from asking clients to come back another day to see an RDH, as we cannot be sure we will have coverage on any given day.

• When an RDH is not available, please use the CF@3 Provider Referral List to help clients obtain dental services. All of the providers on the list accept Medicaid and see children of all ages.

This approach resulted in an increase of RDH time spent working with WIC clients, as demonstrated below:

Typical RDH coverage after first month of implementation: Clinic Monday Tuesday Wednesday Thursday Friday Lakewood All Day NO

COVERAGE All Day Afternoon Only All Day

Arvada All Day No Exam Room Available

All Day NO COVERAGE

NO COVERAGE

Typical RDH coverage after third month of implementation: Clinic Monday Tuesday Wednesday Thursday Friday Lakewood All Day All Day All Day Afternoon Only All Day Arvada All Day No Exam Room

Available All Day All Day All Day

Managing Client Flow Paramount to achieving buy-in amongst WIC staff was a dedication to support their workflow and enhance services rather than compete for clients or disrupt their processes. This was achieved using the following guidelines:

• CF@3 screenings are to occur only after WIC appointments are finished. However, RDHs will set up promotional carts in the waiting room, talk to clients who are waiting for their WIC appointments, and give them paperwork to prepare to be seen after their WIC appointment.

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• Clients with questions about the program can be referred to the peach brochure provided and asked to return to the waiting room to see the dental hygienist.

• Screenings are walk-in only at this time, so we cannot guarantee a client they will be seen promptly.

Orienting RDHs Program Coordinator employed by JCPH spent several days in clinic full-time with each RDH to introduce them to staff, help manage client flow while they became comfortable with the infant oral health model, facility, and supplies, and helped promote program to both WIC staff and WIC clients.

Orienting WIC Staff WIC manager was approached for collaboration before the model was developed. Staff was notified that the services would be integrating by their manager. Program Coordinator and RDH educated WIC staff about services offered and requested feedback about process. WIC staff was overwhelmingly supportive of program and enthusiastically referred clients after WIC appointments.

Pathways for Ongoing Communication Developing direct professional contact between RDHs and WIC staff is imperative to healthy communication amongst front-line service providers. Each RDH was both motivated and professional in developing and maintaining these relationships to increase referrals and maintain optimal patient flow. Occasionally, WIC staff brought up an issue or two with their manager, who then passed that issue to the Program Coordinator to bring up with the RDH. For instance, one WIC counselor was asked to postpone an appointment to translate for the RDH and did not feel comfortable declining even though that was interfering with her work. This was resolved by establishing firm boundaries with the RDHs and reinforcing that the clinic’s main purpose is to deliver WIC services unimpeded and it is up to the RDHs to accommodate their needs.