28 minute read
A Dental Care Coordination System: Experiences in Alameda County, California
Benjamin W. Chaffee, DDS, MPH, PhD, is an associate professor of oral epidemiology and dental public health at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.
Jared I. Fine, DDS, MPH, is a dental public health consultant and former dental health administrator at the Alameda County Public Health Department. Conflict of Interest Disclosure: None reported.
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Yilak Fantaye, MPH, is with community assessment, planning and evaluation at the Alameda County Public Health Department. Conflict of Interest Disclosure: None reported.
Kristin S. Hoeft, MPH, PhD, is an assistant professor of oral epidemiology and dental public health at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.
Rhodora Ursua, MPH, is the director of programs at the Alameda Health Consortium. Conflict of Interest Disclosure: None reported.
Ray Stewart, DMD, MS, is professor and chair of the division of pediatric dentistry at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.
Suhaila Khan, MD, MPH, PhD, is the past project director of Healthy Teeth Healthy Communities of the Office of Dental Health, Alameda County Public Health Department. Conflict of Interest Disclosure: None reported
ABSTRACT
Background: In 2016, the California Department of Health Care Services launched the Dental Transformation Initiative (DTI) to address statewide underperformance in providing dental services to Medicaid-eligible children and youth. The DTI allowed selected counties and other qualified organizations to create Local Dental Pilot Programs (LDPP) to enhance service utilization. Alameda County began Healthy Teeth Healthy Communities (HTHC), a multicomponent LDPP featuring community-based dental care coordination augmented with general dentist training in care for young children.
Methods: This examination provides background, describes HTHC components and presents selected dental care access metrics from HTHC programmatic and state-maintained datasets during the time period of HTHC implementation.
Results: From 2018-2020, 8,609 children and youth (ages 0-20 years) who received HTHC care coordination attended ≥ 1 dental appointment. Of all children and youth HTHC enrolled for care coordination, 87% were scheduled for ≥ 1 dental appointment. Of all first scheduled appointments, 83% were confirmed as attended. In total, 34,749 appointments were scheduled at nine public clinics and 25 private dental practices.
Conclusions: HTHC dental care coordination successfully connected thousands of underserved children and youth with dental care, per program objective. However, additional, larger-scale programs are required for greater impact. Out of > 150,000 child and youth Medi-Cal beneficiaries countywide, only 47% attended a dental visit in 2019.
Practical implications: Successful HTHC program elements can be adapted to other settings. Investments at larger scale and complementary actions to address other access barriers are needed to yield more dramatic increases in dental service utilization at the population level.
Keywords: Dental care coordination, oral health, children, youth, underserved communities, dental care access
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In 2016, the California Department of Health Care Services launched the Dental Transformation Initiative (DTI) under the Medi-Cal 2020 state Section 1115(a) Medicaid Waiver with the goal of improving dental health and access to dental care for California Medicaid (Medi-Cal) beneficiaries ages 0-20 years. [1] State Medicaid demonstrations and waivers are federally authorized and allow states to test new strategies for health care service payment and delivery. [2]
The DTI was designed to respond to a history of underperforming oral health and dental utilization metrics among child and youth Medi-Cal Dental Program beneficiaries. In 2012, the California Dental Association released a landmark access report, “Phased Strategies for Reducing Barriers in Access to Care,” delineating the decades-long challenges in addressing access to care for the 1 in 3 California children eligible for Medi-Cal. [3] In 2014, the California State Auditor’s Report revealed that in 2012-13, only 44% of eligible children and youth under age 20 had accessed the dental care to which they were entitled. [4] By 2014, the restoration of adult dental benefits in Medi-Cal and the expansion of the Affordable Care Act witnessed a more than doubling of the number of total Medi-Cal enrollees to > 12 million, nearly one-third of all Californians. [5] These events placed even greater pressure on a dental provider network that the California State Auditor’s report had just shown to have not provided care for even half of eligible children. In 2015, the Legislature convened the Little Hoover Commission, which issued a critical report on the Medi-Cal Dental Program with a series of program and policy recommendations. [6] Among the commission’s recommendations were setting a goal of 66% of children with Medi-Cal Dental coverage achieving an annual dental visit and the establishment of new pilot projects to increase access with the potential for expansion statewide.
Within this setting, the DTI launched with four domains, the first three of which paid incentives to Medi-Cal Dental providers and featured the following goals: Increase delivery of preventive dental services (Domain 1); increase use of caries risk assessments to drive preventionfocused care (Domain 2); and increase patient continuity of care (Domain 3). Uniquely, Domain 4 created Local Dental Pilot Programs (LDPPs) allowing a California county, consortium of counties, tribe or University of California or California State University campus, among other entities, to address any of the goals of domains 1, 2 or 3 through alternative programs, such as innovative care models, delivery systems or workforce initiatives. Twelve LDPPs were supported under Domain 4. Some program elements common across the pilot programs were dental care coordination, virtual dental home services (in which allied dental personnel provide basic services in community settings with dentists connected via telehealth) and community outreach messaging. [7]
This paper focuses on the Alameda County Office of Dental Health’s LDPP, known as Healthy Teeth Healthy Communities (HTHC), as an exemplative case study of program successes, challenges and limitations to inform future dental health initiatives and policies. Described are outcomes of dental care coordination according to internally tracked outcome metrics, such as success in connecting clients with a dental appointment and appointment attendance.
Alameda County is located in the East Bay region of the San Francisco Bay Area. Geographically, the county ranges from urban marinas to rolling open spaces, parklands and large urban and suburban communities. With over 1.6 million residents, Alameda is the seventh most populous county in California and has 14 incorporated cities and several unincorporated communities. Alameda County is characterized by rich diversity and culture, is home to the University of California Berkeley and 29 other colleges and is a center for the arts, music and international cuisine. Alameda County is one of the most racially/ethnically diverse regions in the San Francisco Bay Area and the nation. [8] Approximately 6% of Alameda County residents fall below the federal poverty level (federal income threshold adjusted for family size), which is less than the statewide percentage (10%) but does not take costs of living into account. [9]
Healthy Teeth Healthy Communities
The Alameda County HTHC was a multicomponent, countywide program supported through the DTI and built upon existing community resources and infrastructure. Many HTHC components were first implemented as part of the Alameda County Healthy Kids Healthy Teeth program, which was limited to children ages 0-5 years at four partner Special Supplemental Nutrition Program for Women, Infants and Children sites. HTHC sought to expand and improve Healthy Kids Healthy Teeth initiatives. The primary aim of HTHC was to increase children’s access to dental services, particularly use of preventive service, via dental care coordination, as stated in its program goal and objective (below).
The HTHC goals: To increase access to and utilization of dental care services emphasizing prevention for child and youth Medi-Cal beneficiaries (ages 0-20 years) in Alameda County. By the end of the project period, 15,000 children will utilize dental care. This will be achieved by creating and implementing a new model of countywide dental care coordination in Alameda County.
HTHC Key Components
Three key components of the HTHC program included:
■ Establishing a linguistically and culturally diverse workforce of community dental care coordinators to strengthen connections between families and dental providers.
■ Offering active outreach, education, technical assistance, consultation and a menu of incentives to local dentists working in federally qualified health centers (FQHCs), community clinics and private practices to enhance their capacity for providing dental services emphasizing prevention to Medi- Cal Dental beneficiaries ages 0-20.
■ Creating a web-based data management system to support care coordination, data tracking, evaluation and quality improvement.
This paper describes each of these key components, assesses client-level outcome measures, such as dental service utilization, and discusses achievements, challenges and lessons learned from the HTHC program.
Collaborations and Partnerships
One key aspect of the HTHC was its ability to leverage and/or forge partnerships with other local programs and organizations. These linkages included public-private entities, dentalmedical-behavioral providers and academia. The 41 contracted HTHC partners included 17 large agencies and 24 private dental practices (In addition, one of the participating private dental offices did not contract with the project). The Alameda County Public Health Department had longtime relationships with most of the agency partners.
Healthy Teeth Healthy Communities: Program Components
Dental Care Coordination
At the core of the Alameda County Dental Health Care Coordination system is the dental care coordinator workforce and the dental providers. The dental care coordinators are the bridge that connects the dental providers and clients. A working dental care coordination model relies on active data collection, analysis and utilization as well as continuous quality assurance through communication and partnerships/collaborations between program leadership and clinical and community partners. The HTHC model follows dental public health principles. It aims to reduce access barriers (as mentioned in the Little Hoover Commission report) to increase dental care utilization by Medi-Cal beneficiaries. Although this model was developed for families with children or youth ages 0-20 years, dental care coordination has the potential to be adapted for other target populations (e.g., adults, seniors, children with special needs, pregnant women or people with unstable housing).
As operationalized in HTHC, dental care coordination required creating a workforce at the community level. The individuals carrying out care coordination were called the community dental care coordinators (CDCCs). The CDCCs’ role is to connect patients, providers and systems. A CDCC is a community health worker, field staff or similar paraprofessional with some specific prerequisite skills, knowledge and experience related to interpersonal communications and working with public health agencies. Any community health worker with these attributes can be trained in dental care coordination; dental knowledge is not a prerequisite. CDCCs primarily helped clients to make dental appointments at service locations convenient for their clients, including locations that had agreed to hold appointment slots open for HTHC referrals. CDCCs were empowered to engage with families who were already existing clients of partnering agencies and health centers (known as “in-reach”) as well as outreach in the community to both individuals and groups. These initial contacts afforded the opportunity to provide motivational information, stress the importance of early preventive dental care and emphasize the value of home hygiene practices and health-promoting dietary practices. Once an initial dental appointment was made by a CDCC, follow-up support was provided with appointment keeping, such as reminder calls. This included ongoing liaising with the dental service location to support continuity of ongoing dental care.
In order to maximize their successful engagement with the beneficiary population, the HTHC CDCCs were recruited as a cross-agency workforce, linguistically and culturally reflective of the community. Twenty-six dental care coordinators from 14 agencies (two county programs, eight FQHCs, two community health centers of which one had a dental clinic and two community-based organizations) were hired and trained. Care coordination sites reflected a leveraging of existing infrastructures for community and patient outreach. The majority (69%) of the CDCCs identified as female, and seven had prior experience working as a dental assistant. As a group, the CDCCs spoke 10 languages fluently: Bengali, Chinese-Cantonese, Chinese-Mandarin, English, Farsi, Korean, Portuguese, Spanish, Tagalog and Vietnamese.
Dental Provider Outreach, Incentivization and Community of Practice
The Community of Practice (COP) was created to address provider-related barriers to access to care for Medi- Cal beneficiaries. The members of this dentist network were supported, trained and mentored to recognize the importance of equitable access to care and overcome the barriers to adequate services often experienced by Medi-Cal beneficiaries. This network recruited 169 dentists (136 from eight FQHCs, two from one community health center and 31 from 25 private dental practices). Most COP members were general dentists who provided care for children but had varying levels of comfort and training in pediatric dentistry. Thus, improving skills and self-efficacy in providing preventive dental services to young children was a key COP goal.
Dental provider outreach, incentivization and recruitment were designed to address potential provider concerns related to working with underserved children. Recruitment began with a mailed invitation to all licensed Alameda County dentists to attend the inaugural convening. That inaugural meeting covered the goals of the DTI, the specific goals and objectives of the HTHC pilot and the incentives available to participating dentists. In addition to statewide Medi-Cal Dental rate increases specially designed to reward increased numbers of preventive services and continuity of care, HTHC would also directly reimburse privatepractice providers for family oral health education (FOHE) for families with young children (for private-practice providers: $20 per visit, up to two visits per year). FOHE consisted of a brief counseling with parents of children ages 0-5 years, emphasizing home oral hygiene practices and healthy dietary behaviors. FQHC providers were also encouraged to deliver FOHE but without monetary incentives.
COP member dentists were assigned one or more CDCC to support families in navigating their way to dental appointments. While the HTHC program prioritized care for young children, member dentists could determine the number and ages of children for whom they would make appointments available. Over three years, the COP offered 14 continuing dental education (C.E.) courses at no cost, mostly led by faculty from the University of California, San Francisco, School of Dentistry. C.E. topics focused on increasing the confidence and competence of dentists to serve young children. COP dentists were overwhelmingly general practitioners. Thus, 17 pediatric dentistry specialists were recruited to serve as mentors to COP members, offering support on treatment planning and accepting referrals of complex cases.
C.E. courses were offered quarterly and served as a tangible benefit to COP member dentists. The COP strove to become “a learning community of dentists.” Beyond the C.E. courses, COP gatherings were an opportunity to bring together dental professionals who shared a commitment to providing care to Medi- Cal-enrolled children and youth with the greatest need and, often, the most barriers to accessing the services to which they were entitled. Some individual COP dentists convened with HTHC staff to delineate programmatic and contractual details, including the role of the CDCC, scheduling appointments, use of dental encounter forms and invoicing. Frequently, it was in these person-to-person meetings and regular visits by CDCCs where any difficulties in working with the HTHC pilot or Medi-Cal administrative requirements were addressed.
Dental Care Coordination Management System
The care coordination management system (CCMS) is a web-based, HIPPAcompliant data hub, linking the various CDCC employers, dental care service providers and other HTHC participating organizations. The CCMS uses an innovative, structured data approach, similar to coding systems, such as CDT and ICD-10, to document care coordination activities. The CCMS allows dental care coordination data aggregation across multiple providers to deliver a broad picture at both the individual patient and the population level. The user interface is readily navigated and allows for client enrollment and appointment tracking (both scheduling and recording appointment outcomes). The CCMS database enabled the 26 CDCCs to simultaneously enter and use data. HTHC project performance was monitored with the data from the CCMS database, and relevant feedback was given to the partners monthly and quarterly. The CCMS was designed specifically for HTHC and is not widely available as commercial software as of this writing.
Data Sources
Alameda County Dental Care Coordination
Data from the HTHC care coordination management system, covering clients who were enrolled in dental care coordination from Jan. 1, 2018, through Dec. 31, 2020, are presented as descriptive counts and percentages. After describing the client population, two main outcome metrics were calculated: 1) dental appointment scheduling (of all unique children enrolled in care coordination, how many were scheduled for ≥ 1 dental appointments); and 2) scheduled dental appointment outcomes (of all children with a scheduled appointment, how many of those appointments were confirmed as kept).
Publicly Available State and County Data
For this case study, measures of Medi-Cal Dental service utilization in Alameda County and California were calculated from publicly available reports posted at the California Health and Human Services Open Data Portal. [10]
Dental Access: Quantitative Results
HTHC Care Coordination
Over three years (2018 to 2020), 8,609 children and youth (ages 0-20 years) who received care coordination through HTHC successfully attended ≥ 1 dental appointments. These young people represented the majority (72%) of the 11,930 unique child clients the HTHC dental care coordination program enrolled during this time period. Nearly half the enrolled clients (48%) were age 5 or younger and 82% had not visited a dentist in the 12 months preceding program enrollment (TABLE 1), demonstrating a programmatic emphasis on increasing access for young children. While some clients presented with urgent dental treatment needs, the vast majority (94%) did not, suggesting an opportunity for early preventive care. More than half of clients (54%) identified as Hispanic or Latino (TABLE 1).
Of all HTHC clients, 87% were scheduled for ≥ 1 dental appointments via care coordination (TABLE 2). Most who were connected with a dental appointment were scheduled at an FQHC or public clinic (TABLE 1). Appointments were made at dental service locations throughout Alameda County (including clinics with multiple sites). From 2018-2020, of 34,749 scheduled appointments (including multiple appointments per child), 23,090 were scheduled at nine public clinics (eight FQHCs and one community health center) and 11,659 were scheduled at 25 private dental practices.
First-appointment scheduling success exceeded 80% in all demographic groups assessed, with the exception of clients aged ≥ 18 years, among whom only 66% were scheduled for a dental appointment. Despite widespread success, some racial/ ethnic disparities persisted (TABLE 2). For example, clients identified as Asian Pacific Islander were more likely to be scheduled for a dental appointment (93%) than clients identified as African American or Black (80%). While client volume decreased substantially in 2020 during the COVID-19 pandemic, the percentage of clients scheduled for a dental appointment remained high (TABLE 2).
Most HTHC-scheduled dental appointments resulted in a successful dental encounter on the date of the appointment (TABLE 3). HTHC care coordinators were able to record the dental appointment outcome (kept, no show or rescheduled) for 99% of all first dental appointments made for HTHC clients, and 83% of those appointments were kept. While success in keeping dental appointments was high in all demographic groups examined, some disparities emerged. Similar to appointment scheduling, clients identified as Asian Pacific Islander were more likely to keep their first dental appointment (90%) than clients identified as African American or Black (74%). Clients appointed at a public clinic or FQHC were more likely to keep their first appointment as scheduled (91%) than clients appointed at a private-practice location (72%), with fewer no-show, reschedule and unknown outcomes (TABLE 3). Children categorized with the highest urgency of treatment needs were more likely to keep their scheduled appointment (94%) than children with less urgent needs (TABLE 3).
Of the 10,396 clients scheduled for a first dental appointment, most (74%) were scheduled for a subsequent appointment, either for continued treatment or a routine recall visit. Success in keeping a scheduled visit was somewhat diminished for subsequent appointments: 70% of all follow-up appointments were confirmed as kept, with a greater percentage of no-show (21%), reschedule (5%) and unknown (4%) outcomes than for first appointments.
State and County Trends
According to publicly available California state data, > 150,000 children and youth ages 0-20 years were eligible for Medicaid benefits in Alameda County in 2019 (TABLE 4), more than 1 in 3 children and youth in the county. Of eligible beneficiaries, 47% had at least one dental service provided, slightly below the statewide dental service utilization percentage (50%) for this age group (TABLE 4). Both statewide and in Alameda County overall, utilization differed by age and race/ethnicity (TABLE 4). Children ages 3-14 years were more likely to receive dental services than younger or older children. Racial/ethnic differences in Alameda County mirrored those in the state, with utilization highest among children identifying as Asian or Hispanic/ Latino and lower among children identifying as Black or white.
Dental service utilization among Alameda County Medicaid-eligible children followed statewide trends from 2013-2019 (FIGURE 1). Alameda County utilization matched statewide utilization among children ages 0-5 years but trailed by a few percentage points among older children (FIGURE 1). Compared to years 2013-2016, both statewide and countywide dental utilization was higher following DTI implementation in 2017; however, increased utilization in 2019 likely reflects the inclusion of fluoride varnish applications in medical settings, which was not counted as a dental service in utilization calculations for years 2013-2018. Thus, increases cannot necessarily be attributed to the DTI.
Discussion
Over a three-year period, the dental care coordination component of the Alameda Healthy Teeth Healthy Communities program successfully connected more than 8,000 children and youth with dental services by overcoming system navigation barriers via linguistically and culturally sensitive support, motivation and anticipatory guidance from CDCCs. Not only were clients scheduled for dental appointments, but with prompting and assistance from CDCCs, the vast majority of appointments were attended as scheduled, benefiting patients and dental providers alike. Care coordination was especially successful for younger children (ages < 5 years) and for those connected with care at FQHCs or other public clinics. This focus on younger children, especially those without a prior dental visit, suggests that the program was able to direct children for preventive care before more serious dental problems developed. While care coordinators served as a bridge between patients and dental providers, the overall HTHC program also strengthened collaboration between the Alameda County Office of Dental Health, dental care providers and organizations and other local partners, all of whom shared information and resources to build the HTHC program.
To date, care coordination in dentistry has generally been more limited than analogous efforts in medicine, with many existing dental care coordination programs focused on increasing dental care access for specific vulnerable populations, such as persons living with HIV/AIDS [11,12] or patients with disabilities. [13] The American Dental Association supports care coordination as a solution to access-to-care barriers, launching its own Community Dental Health Coordinator program in 2006. [14] In a large multispecialty group dental practice in the Pacific Northwest, existing office staff were recently “upskilled” to dental care coordinators to improve patient attendance and strengthen connections between providers and patients. [15] Under strong managerial support, the new role was largely viewed positively within the organization, but long-term outcomes are yet to be evaluated. [15]
Among care coordination programs aiming to enhance dental utilization among Medicaid-eligible children, a retrospective analysis of patient records from one urban pediatric dentistry clinic reported only modest improvements in appointment attendance, although care coordination primarily consisted of appointment-reminder telephone calls. [16] A dental care coordination intervention trial featuring case managers in Louisville, Kentucky, also reported improvements in dental appointment access, but the number of patients involved was small. [17] On a somewhat larger scale, a dental care coordination pilot project in New York successfully recruited dental providers and clients, leading to substantial countywide increases in dental utilization by Medicaid eligible beneficiaries in the one small rural county where the program focused. [18] To our knowledge, there are no existing reports describing a public health agency-driven dental care coordination program in as populous or diverse a setting as Alameda County.
A unique aspect of HTHC care coordination was an electronic data management system that allowed opportunities for near real-time data monitoring, evaluation and program improvement. Undoubtably valuable, there were drawbacks to conducting care coordination through a single electronic platform. Learning the system required dedicated training time, and assuring highquality data required frequent centralized monitoring. Data entry was a timeconsuming responsibility for CDCCs, who often balanced additional job duties. The CCMS system was custom designed for HTHC, making transfer to other settings more challenging.
HTHC care coordination was particularly effective with young children and at well-established FQHCs. Encouragingly, participating private practices also accounted for a sizable portion of patient appointments. Appointments were more likely to be kept at public clinics than private practices, on average, but there was considerable variation across individual sites. Speculatively, the fact that many FQHC appointments were for clients identified via in-reach (for example, patients who had received medical, but not dental, care from the same FQHC site and were thus familiar with the clinic and setting) may have contributed to better appointment success.
While the Little Hoover Commission recommended that California counties steer more Medi-Cal-eligible patients to FQHCs with capacity to treat them, [6] greater involvement from private practices may be essential to reach utilization goals when FQHCs are at or near their capacity limits. Alameda County is home to multiple FQHCS with ample capacity to provide dental services; a greater role for private practices might be needed in other settings. In HTHC, provider incentives made available through the Community of Practice may have played a role in bringing private providers into the program. Nonetheless, the total number of private practices that agreed to accept HTHC appointments was only a fraction of all practices throughout the county.
Despite impressive utilization metrics overall, access disparities within the HTHC enrollee population mirrored those observed at the county and state level, particularly for Black children and youth. Should HTHC or similar programs continue, a greater level of outreach and involvement of Black communities, along with greater representation among CDCCs and dental providers, is strongly recommended.
Positively, HTHC was highly successful in enrolling young children. Whereas children ages 0-5 make up slightly more than 27% of Medi-Cal beneficiaries in Alameda County, this age group comprised nearly half (48%) of HTHC enrollees. Connecting young children with a dental home early in life, before dental caries necessitates more costly and invasive treatment, is a critical component of prevention-focused dental care, especially for high-risk children. [19] Children with existing urgent treatment needs comprised a small portion of the HTHC client population. These children, particularly urgent Class 4, may experience oral pain or infection. Notably, these children were the most likely to be connected with (and keep) a dental appointment, indicating both programmatic success and, potentially, heightened caregiver motivation.
As with nearly all health systems worldwide, the COVID-19 pandemic severely disrupted the HTHC program. The volume of HTHC referrals dropped substantially in 2020, especially in the spring months when most dental service locations were closed to all but emergency care. Serious concerns remain about families forgoing, postponing or being unable to access needed dental care. One innovative approach to lessen pandemic-related access barriers in Alameda County was the launching of a drive-through dental clinic at one FQHC. [20] Multiple service locations turned to teledentistry visits to reach their patients during the pandemic, potentially accelerating widespread uptake of this technology, which could lead to long-term access improvements. [21] During the pandemic, the HTHC COP maintained ongoing opportunities for interaction and continuing education through quarterly sessions conducted over a virtual meeting platform.
The HTHC program connected more than 8,000 children and youth with dental appointments, many of whom reported not having visited a dentist in the prior 12 months. HTHC was internally successful in achieving very high percentages of appointment scheduling and attendance among its clients. However, when looking at Alameda County as a whole, the overall percentage of Alameda County Medi-Cal beneficiaries ages 0-20 years with a dental appointment in 2019 (the most recent data available) was not meaningfully improved from prior years relative to the analogous percentage statewide. While HTHC achieved success among the children it reached, given resource constraints, the capacity of the HTHC dental care coordination program was at least an order of magnitude smaller than the number of child and youth Medi-Cal beneficiaries in the county. Thus, driving meaningful changes in dental utilization at the county and state levels will require much greater investment of resources than was available for local pilot projects through the DTI.
Among limitations in evaluating the HTHC program is the lack of an experimental design. For practical and ethical reasons, there was no noncare coordination control group, limiting the ability to draw conclusions about program effectiveness. Also, HTHC was designed with multiple components, including dental provider education and incentivization. Untangling the specific contributions of each component to any access to care improvements was not possible.
Conclusions
The Alameda County Healthy Teeth Healthy Communities program, developed under the California Dental Transformation Initiative, successfully utilized dental care coordination and a network of support for local dental providers to connect underserved children with access to dental care. The ability of dental care coordination and other program components to address potential access barriers at the patient, provider and system levels all plausibly contributed to programmatic success. Investments at larger scale and complementary actions to address other potential access barriers are recommended to yield more dramatic increases in dental service utilization at the population level.
ACKNOWLEDGMENT Heathy Teeth Healthy Communities is a project (Domain 4) of the Local Dental Pilot Program (LDPP) under the Dental Transformation Initiative (DTI), funded by the California Department of Health Care Services (DHCS). The authors thank the leadership of Alameda County for their constant support for this project: Colleen Chawla, director, health care service agency, Kimi Watkins-Tartt, director, public health department, and Quamrun Eldridge, director, community health services division. They also thank Arash Aslami, Office of Dental Health, Alameda County Public Health Department, for support and administration of the Heathy Teeth Healthy Communities Project.
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THE CORRESPONDING AUTHOR, Benjamin W. Chaffee, DDS, MPH, PhD, can be reached at Benjamin.Chaffee@ucsf.edu.
