Care Coordination: A Valuable Adjunct To Dental Practice - Lessons Learned in a Public Health Setting

Ellen Darius, RDH, MS, MPH, received her BS and MS in dental hygiene from the University of California, San Francisco. She spent several years as a dental hygienist in private practice and served as assistant clinical professor at the UCSF School of Dentistry. She participated in several research studies and received her MPH from UC Berkeley. Conflict of Interest Disclosure: None reported.

Huong Le, DDS, MA, is the chief dental officer at Asian Health Services (AHS). She is also a faculty member at the University of California, San Francisco, School of Dentistry, Western University College of Dental Medicine, Arizona School of Dentistry and Oral Health, University of the Pacific and California Northstate University College of Dental Medicine. Conflict of Interest Disclosure: None reported.

Sridevi Ponnala, BDS, DDS, MBA, is the chief integration officer/EVP of the Tiburcio Vasquez Health Center. She also has a faculty appointment with the University of the Pacific, Arthur A. Dugoni School of Dentistry and the Chabot College dental hygiene program. Conflict of Interest Disclosure: None reported.

Curtis Le, DMD, is a graduate of the Arizona School of Dentistry and Oral Health and AEGD residency program at the University of California, San Francisco, School of Dentistry, adjunct faculty of Western University School of Dental Medicine, an MPH candidate at A. T. Still University and a staff dentist at Bay Area Health Center. Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: Children and youth with special health care needs (CYSHCN) face numerous barriers in accessing dental care including a lack of providers who are comfortable and competent in addressing their needs. Care coordination is an effective and financially viable tool to navigate the complexities of the health care system and match patients to providers with the appropriate training and facilities to treat their specific needs. Care coordinators have been shown to improve access, reduce barriers and decrease health care costs for CYSHCN.

Objectives: To present results of a care coordination pilot in two federally qualified health centers that worked with community dental care coordinators (CDCCs) as part of the Healthy Teeth Healthy Communities (HTHC) project to determine if this model is financially sustainable and potentially beneficial to connecting CYSHCN to dental care.

Methods: Several case studies were examined to determine the efficacy of the care coordination model with regard to improving oral health outcomes by decreasing barriers to care for CYSHCN. Data were analyzed from two federally qualified health centers that participated in the dental care coordination pilot.

Results: The results illustrate a positive correlation between care coordination and patients’ ability to establish a dental home. The data also show a decrease in the number of no-shows for the patients supported by care coordinators.

Conclusions: This pilot demonstrated that care coordination improves access and continuity of care for all patient populations. Additional research and funding should be afforded to further investigate care coordination programs as a bridge to better oral health care for CYSHN.

Keywords: Special needs dentistry, community and public health dentistry, vulnerable patients, pediatric dentistry

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Children and youth with special health care needs (CYSHCN) have at least one chronic physical, developmental, behavioral or emotional condition that requires more than routine health and related services. 1 These children and their families face myriad barriers to health care including inadequate or inconsistent access to pediatric specialists, the need to manage multiple providers in disparate care systems and the high financial burdens associated with complex care.

Quality dental care may be particularly difficult to attain due to a lack of providers with adequate training or who can provide necessary accommodations or who are willing and able to spend the extra time to provide specialized care to this population. According to the American Academy of Pediatrics, “optimal outcomes for children and youth, especially those with special health care needs, [require] interfacing among multiple care systems and individuals … [thus,] coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care and improvement in the patient/family experience of care.” [2]

A study by Williams et al. describes the barriers to dental care access faced by patients with special health care needs (SHCN) in an affluent metropolitan community. [3] This study delineates the difficulties faced by these patients in a community that should be financially and socially able to provide dental care to this population. The study’s surveys showed a severe shortage of providers who are comfortable and competent in addressing the complexities presented by the growing SHCN population. The polled families reported approximately 20% of the SHCN community are without a dentist. Access to care was even more impacted for those SHCN patients of lower socioeconomic status. Making dental care coordination available to CYSHCN is an effective and financially viable tool for helping their families navigate the complexities of the U.S. health care system. The October 2020 National Academy for State Health Policy (NASPH) Report refers to care coordination as “[a] core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden and decrease health care costs for children and adults with chronic and complex conditions.” [4] In addition to the NASPH’s list of care coordination benefits, care coordinators can provide patient advocacy in a way that reduces the potential for patient distrust of providers. Patient-centered advocacy by care coordinators prevents complex patients most in need of care from avoiding care and being noncompliant with treatment recommendations. In addition, care coordinators are in a position to foster trust and empower the communities they serve by addressing commonly cited physical and social barriers to care such as language and cultural differences. [5]

Care coordination has existed for years in medical clinic settings. Yet, in dental care settings it is a relatively new concept. The limited data looking at dental care coordination point to positive social and financial outcomes. In 2005, Willamette Dental Group (WDG) in Oregon piloted a project to utilize dental care advocates (DCA) to take advantage of new Oregon Medicaid care coordination financial incentives. Although the results were only preliminary, WDG demonstrated a model of care coordination that could work in dentistry. In the closing remarks of their study, WDG leadership believed DCA to have practice improvement potential through “motivational interviewing.” The DCAs “helped patients to understand and follow through with recommended prevention and treatment services, how to receive and properly use prescriptions and home care products, scheduling recall appointments and troubleshooting barriers the patients might face.” The pilot program concluded that DCAs can establish a “trusting and engaged relationship with the patient.” [6] The DCAs were trained in additional skills such as motivational interviewing and understanding different medications and dental products so as to help answer patient questions and engage patients in oral health care. With care coordinators helping providers and patients to align expectations and expedite care, compliance rates go up, no-shows go down and financial benefits become realized as time and money are saved. This concept translates into value-based care, reducing costs for organizations and patients alike.

Community Health Workers

Perhaps the most important benefit of employing community health workers (CHWs) is their ability to match patients to providers or organizations with the appropriate training and facilities to treat the patient’s specific needs. This works particularly well for patients with SHCN because of the additional impact of education, transportation facilitation and appointment coordination using culturally sensitive, language-appropriate communications. In the article, “Dental Health in Persons With Disabilities,” Devinsky et al. state that “systemic and structural barriers limit dental health for individuals with [SHCN], who have poorer dental hygiene, higher rates of dental disorders and less access to oral care … that patients with SHCN struggled inordinately with accessibility, comorbidities and communication challenges which intensified the barriers of access to care.” [7] The study concludes that strong care coordination and communication between dentists, caregivers and other providers are essential for positive outcomes. The authors emphasize that the current dental health care system has failed to meet the basic needs of the SHCN community. They conclude that the comfort and dignity of the patient are of paramount importance and would benefit greatly from the adoption of the care coordinator model.

CHWs facilitate appointment-making and compliance with treatment recommendations and increase show rates.

Paul Glassman, DDS, MA, MBA, writes in another article in this issue of the CDA Journal that the “hassle factors” of dealing with the complexities of intaking and appropriately scheduling and appointing patients with SHCN prevent many dentists from considering providing care to people with SHCN. This can be reduced or eliminated by adopting the care coordination model. Care coordinators can provide a thorough medical and dental history as well a comprehensive explanation of a patient’s needs and required accommodations prior to the first appointment. This makes the initial visit more tolerable for both patient and provider and decreases the time needed for comprehensive care.

CHWs play a critical role for CYSHCN, connecting them with appropriate dental care while providing culturally and linguistically appropriate outreach, information, referrals, health education, emotional support and connection to tangible services such as accessible transportation to appointments. Job titles for CHWs differ between and even within health care systems where they may be variously termed “patient navigators,” “community health advisors” or “promotores de salud.” Witmer et al. describe CHWs as “community members who work almost exclusively in community settings and who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate care.” [8] The American Public Health Association defines CHWs as “frontline public health workers who are trusted community members and have an unusually close understanding of the community served.” [9] Often, CHWs live and work within their targeted community and have existing connections with both community members and dental providers. This trusting relationship enables CHWs to serve as a critical link between health services, social services and the community, facilitating access to services and improving the quality and cultural competency of service delivery. [10]

CHWs are relatively inexpensive to train, making enhanced care coordination a scalable model for improved access to dental care for CYSHCN that can be adopted by individual practices or across entire health systems. CHWs facilitate appointment-making, compliance with treatment recommendations and increase show rates. By increasing preventive care for CYSHCN, they reduce the likelihood of emergency care and costs of expensive emergency room visits. Finally, hiring and training community members within marginalized communities to provide care coordination services for CYSHCN builds community strength through economic and social empowerment.

Healthy Teeth, Healthy Communities and Care Coordination

In 2017, the Alameda County Public Health Department implemented the Healthy Teeth, Healthy Communities (HTHC) pilot, a local dental pilot project of the Dental Transformation Initiative. [11] The project timeline was four years (April 2017 to December 2020). The HTHC project was an interagency collaborative to implement a countywide dental health care coordination system to ensure that Medicaid-eligible children ages 0 to 20 in Alameda County receive dental care emphasizing prevention and continuity of care services necessary to ensure their long-term dental health. The program successfully linked more than 10,000 children and youth, some of whom were CYSHCN, to available dental care providers. The grant funded 26 culturally and linguistically sensitive CHWs, referred to as community dental care coordinators (CDCCs).

The idea of using CDCCs to increase access to dental care for underserved populations was inspired by the work of the American Dental Association (ADA) community dental health coordinator program. In 2006, the ADA established the community dental health coordinator pilot program to address the barriers that prevent underserved rural, urban and American Indian communities from receiving regular dental care and enjoying optimal oral health. [12]

In the HTHC pilot, CDCCs were hired and trained to work in 14 networks throughout the county including Asian Health Services (AHS) and Tiburcio Vasquez Health Center (TVHC). The CDCCs’ primary responsibility was to work closely with families and providers to connect children to dental care and ensure they received follow-up appointments. CDCCs initiated first contact with the clients and enrolled them into the practice with their consent. They then set up the patients’ appointments with dental offices and accompanied patients to their first appointment. They also oversaw the continuation of care and assisted in making preventive care appointments for at least six months to a year later. The success of HTHC care coordination is seen at both AHS and TVHC, so much so that TVHC retained and expanded the role of care coordination to all age groups. The CDCCs are recruited from the communities where they are expected to serve, and they receive a comprehensive eight-week training curriculum that emphasizes the importance of access to dental care as part of overall health. They are supported in connecting with peers and providers within the community where they serve this target population. Since implementation, CDCCs have conducted outreach activities, provided assistance in navigating the Medicaid dental program, educated families about oral health, scheduled appointments and maintained close relationships with dental providers.

The CDCCs are recruited from the communities where they are expected to serve.

Asian Health Services

Utilizing funds from the HTHC grant, AHS hired two CDCCs, one who speaks Chinese and one who speaks Vietnamese, to serve its two largest patient groups. They attended various health fairs and reached out to community members who were eligible and who needed dental care. The CDCCs provided an overview of the HTHC program, patient education and, if parents consented, scheduled appointments for dental examination and continuing care visits as indicated. The coordinators handled registration in advance of appointments that saved significant time for the in-office checkin process. Prior to a child’s first dental visit, the CDCCs prepared the parents using patient education modules. Because families were prepared, the children knew what to expect upon arrival at the dental office including the clinic flow as well as procedures such as tooth counting, use of air and water and the associated noises. This created a tolerable and sometimes pleasurable first encounter. Care visits became shorter by approximately seven to 10 minutes per visit due to parents and patients being well prepared because most of their questions were answered prior to the encounter.

Like many dental practices, AHS was severely impacted by the pandemic in 2020. Children were no longer seen regularly in person for various reasons, such as restrictive COVID-19 guidance on dental practices, reduction in services, parental fear of contracting COVID-19 and many others. Fortunately, the children were still connected with their dental home through telehealth. Teledentistry allowed families to stay in contact with their CDCCs who continued to encourage good oral hygiene habits and connect patients with providers as needed for clinical consults and interventions. Although the pandemic resulted in a significant reduction of in-person appointments and outreach activities, the care coordination for these children continued.

Based on the HTHC annual report published in late 2021, the no-show rate for AHS HTHC-enrolled patients was lower than 5%, compared to an 8% no-show rate for the general patient population. This low no-show rate for the HTHC-enrolled children was primarily attributed to care coordination. A true benefit of the HTHC program was the fact that 985 children found a dental home. This is demonstrated by approximately 99% of the enrolled children returning for subsequent continuity of care visits. The recall rate for non-HTHC patients at the health center was only 90% during the same time period. Although the compensation for CDCCs is higher than that of an average front office staff, the number of new patients brought into the practice, the low noshow rate and the shorter time spent for each appointment has made care coordination financially sustainable.

At AHS, the CYSHCN population enrolled in the HTHC was relatively small, approximately 2% of the entire patient population. After their initial visits, all children enrolled in HTHC remained in the clinic system for their continuity of care. This was a result of the work that the care coordinators provided to the families. These patients were treated by three pediatric specialists on staff at the health center. Those who required hospital care were referred to the hospital dentistry program for treatment. The SHCN patients undoubtedly benefited due to the continuity of care that was provided, especially during the pandemic with its increased patient isolation and other challenges.

The AHS clinic also implemented a drive-thru fluoride varnish program in May 2020. CDCCs helped with the telehealth and drive-thru fluoride varnish programs. The dental staff conducted oral health assessments and applied fluoride varnish as indicated while the children remained seated in their car. The program was particularly well received by parents of SHCN patients. One mother of a child with autism told our staff how happy she was that we implemented the drive-thru varnish program. Her son was able to receive the preventive services without challenges. He always had a difficult time coming into the office. Their visits typically ran longer because of the amount of time and resources needed to make him feel comfortable. At the drive-thru, he could remain in his car seat, a place of comfort and safety for him. As a result, he was happy and cooperative with the provider.

One CDCC said, “This month I came across a 2-year-old patient who had come back for her four-month fluoride appointment. At her first appointment, she was uncooperative from the moment she stepped into the waiting room, and her mother had to restrain her the entire time during her appointment. At this second appointment, she was enjoying herself in the waiting room and cheerfully greeted me. She and her mom recognized me and we had a nice chat, and her mom was very happy that her daughter was more comfortable with the clinic. It was an overall positive interaction.” Because of this positive experience, the mom asked if her son could also come to this clinic. The CDCCs became great ambassadors for the practice and provided added value to the dental program.

What Staff and Parents Said

“This month I came across a 2-year-old patient who had come back for her fourmonth fluoride appointment. At her first appointment, she was uncooperative from the moment she stepped into the waiting room, and her mother had to restrain her the entire time during her appointment. At this second appointment, she was enjoying herself in the waiting room and cheerfully greeted me. She and her mom recognized me, and we had a nice chat, and her mom was very happy that her daughter was more comfortable with the clinic. It was an overall positive interaction.” CDCC

“I am very grateful for helping me find such timely appointments for my kids. Without your help, I would not even have known how to access care for my child. Thank you.” P.T.

“I was completely unaware that I had to brush my daughter’s teeth because no one has ever told me or shown me how to do it. I wasn't told to do it by my pediatrician. So, I had never brushed her teeth before until now." Parent

Tiburcio Vasquez Health Center

TVHC hired two CDCCs through the HTHC pilot project. With the addition of these CDCCs, the TVHC’s dental program gradually saw an increase with enrollment and utilization of dental services for children ages 0 to 20. This was achieved through “in-reach” and outreach efforts by the CDCCs. Moreover, there was improvement in patients’ compliance with appointments and continuity of care. Care coordinators also enrolled CYSHCN and supported them to ensure accessible health care services met their needs. Evidence has shown the effectiveness of care coordinators and the lessons learned from using this model especially with CYSHCN who are covered by Medicaid. [13]

Some of the tangible outcomes were reduction in no-show rates and increased continuity of care for clients enrolled in the HTHC program and served by the CDDC compared to other patients in the same age group not enrolled in the program. When we compare the noshow data, there is approximately a 6% variance between the no-show rate in patients enrolled in HTHC compared to nonenrolled patients. The other significant outcomes were increased patient satisfaction and increased access to dental care for children ages 0 to 20 due to outreach conducted by CDCCs. Due to efforts of CDCCs, 1,335 children established a dental home with TVHC . This also includes CYSHN who account for about less than 3% of children enrolled in the program. Most of the children who were enrolled into the program were high risk and their dental care was managed by a pediatric dentist and general dentist. Some of the patients were referred to hospital dentistry that was coordinated with the support of CDCCs. Due to the impact of CDCCs on the work, TVHC added CDCCs to the budget after termination of the HTHC grant in December 2020. It is very important to invest in the necessary infrastructure to see positive health outcomes. Building an effective health care infrastructure that meets the oral health needs of all Americans and integrates oral health care effectively into overall health is critical. [14]

The pandemic affected all dental programs, causing a disruption in dental services for many patients across the United States. However, the families working with CDCCs were comfortable coming in for their dental appointments due to the trust and relationship they had with their CDCC. Despite the pandemic, families who had high-risk children between ages 1 and 5 remained compliant with drive-thru dental visits and fluoride varnish applications.

What Parents Said

“As a parent of four children, I was helped by a care coordinator with coordinating dental appointments and educating my children on the importance of dental care. This has been extremely helpful for my family, as two of my children needed to see a specialist.” V.V.

“The care coordinator is very friendly and helpful. This made a huge difference in my family and has taken away stress that I used to have about taking my special needs child to the dentist.” F.C.

Conclusion

Currently, care coordination models are not supported or funded by public or private payers, and policy revision is needed. The families with CYSHCN often experience care gaps because they have to navigate complex health care systems. The support provided by care coordinators is critical to removing the pervasive barriers to care faced by these families. However, there is no systematic billing process or incentives associated with this important care coordinator role.

Care coordination has a large impact on patient oral health outcomes due to the increase in patient engagement and appointment attendance. The data provided by the recent state-funded care coordination program show a decrease in the number of no-shows and an increase in treatment completion rates for the patients supported by care coordinators. The CHW position pays for itself by generating revenue with patient appointment compliance, supporting and empowering providers with managing patients’ complex needs, thereby improving a patient’s overall health.

In the Alameda County dental clinics, care coordination begins when a care coordinator initiates contact with the client and enrolls them into the clinic with their consent. They then set up the patient’s appointments with dental offices and accompany patients to their first appointment. For six months to a year, the care coordinators oversee continuation of care and assistance in making preventive care appointments. The continued success of HTHC care coordination is seen at AHS and TVHC. In fact, at TVHC the care coordinators have not only been retained but their role and scope of care has expanded to all age groups.

The initial expense of hiring care coordinators is compensated by the increased revenue and return on investment from increased continuity of care and reduced no-show rates.

Medi-Cal is transitioning to valuebased care focusing on more equitable, coordinated and whole-person care. The Department of Health Care Services is in the process of implementing the CalAIM dental initiative centered around pay-for-performance applied to preventive services, continuity of care and establishment of dental homes for Medi- Cal patients. [15] CalAIM incentives support the hiring of care coordinators who are key to achieving pay-for-performance measures such as increased patient engagement and improved oral health outcomes.

The HTHC examples at AHS and TVHC as well as the other programs cited clearly demonstrate that care coordination improves access and health outcomes for all patient populations. This care coordination model needs further study especially for high-needs patient populations such as seniors and SHCN patients and their families. For the tangible financial and care benefits, private health care systems should consider providing reimbursement for dental care coordination for all patients, especially those with SHCN. As demonstrated in these pilot projects, this model can reduce costs to the system, reduce stress on families and ultimately improve health outcomes. Under its new CalAIM initiative, Medi-Cal has approved care coordination as a reimbursable service. It is our hope that in California, dental practices will increase their utilization of care coordinators in order to bring better care to SHCN patients.

REFERENCES

1. Lucile Packard Foundation for Children’s Health.

2. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and familycentered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics 2014 May;133(5):e1451–60. doi: 10.1542/peds.2014-0318.

3. Williams JJ, Spangler CC, Yusaf NK. Barriers to dental care access for patients with special needs in an affluent metropolitan community. Spec Care Dentist Jul–Aug 2015;35(4):190–6. doi: 10.1111/scd.12110. Epub 2015 Apr 19.

4. National Academy for State Health Policy. National Care Coordination Standards for Children and Youth with Special Health Care Needs. Oct. 2020.

5. Natale-Pereira A, Enard KR, Nevarez L, Jones LA. The Role of Patient Navigators in Eliminating Health Disparities. Cancer 2011 Aug;117(15 Suppl):3543–52. doi: 10.1002/ cncr.26264.

6. Kottek A, Hoeft K, White J, Simmons K, Mertz E. Implementing care coordination in a large dental care organization in the United States by upskilling front office personnel. Hum Resour Health 2021 Apr 7;19(1):48. doi: 10.1186/s12960-021-00593-0. PMCID: PMC8028788.

7. Devin O, Boyce D, Robbins M, Pressler M. Dental health in persons with disability. Epilepsy Behav 2020 Sep;110:107174. doi: 10.1016/j.yebeh.2020.107174. Epub 2020 Jun 9.

8. Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH. Community health workers: Integral members of the health care work force. Am J Public Health 1995 Aug;85(8 Pt 1):1055–8. doi: 10.2105/ajph.85.8_pt_1.1055. PMCID: PMC1615805.

9. National Academy for State Health Policy. State National Care Coordination Standards for Children and Youth with Special Health Care Needs. October 2020.

10. American Public Health Association. Community health workers.

11. Alameda County Public Health Department, Office of Dental Health. Alameda County’s Local Dental Pilot Program Healthy Teeth Healthy Communities 2017-2020, Final Report. March 2021.

12. American Dental Association. Community dental health coordinator program celebrates 15 years of bringing more people into oral health system.

13. Stewart KA, Bradley KWV, Zickafoose JS, Hildrich R, Ireys HT, Brown RS. Care coordination for children with special needs in Medicaid: Lessons from Medicare. Am J Manag Care 2018 Apr;24(4):197–202. PMID: 29668210.

14. U.S. Public Health Service, Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.

15. Safety Net Clinic Billing Instructions for CalAIM Dental Initiatives.

THE CORRESPONDING EDITOR, Ellen Darius, RDH, MS, MPH, can be reached at Ellen.Darius@acgov.org.