Smiles Across America Webinar Series Strategies to Increase Oral Health Care Access for Children in Medicaid: The Power of Collaboration
Date: 12/15/20105
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OUR MISSION Oral Health America’s mission is to change lives by connecting communities with resources to drive access to care, increase health literacy, and advocate for policies that improve overall health through better oral health for all Americans, especially those most vulnerable.
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Advancing access, quality, and cost-effectiveness in publicly financed health care
Working to Improve Oral Health for Children in Medicaid: The Power of Collaboration December 15, 2015
Supported by the DentaQuest Foundation
www.chcs.org
Agenda I.
Overview of Children’s Oral Health in Medicaid
II.
Working Collaboratively with Managed Care
III. Women, Infants, and Children (WIC) Pay-for-Prevention Project IV. Pursuing Legislative Change V.
Leveraging Existing Resources
VI. Statewide Collaborative Efforts VII. Questions
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Presenters Stacey Chazin, MPH, CHES Director of Prevention Programs Center for Health Care Strategies Jessica Lipper, MSJ Program Officer Center for Health Care Strategies Katherine Libby Program Director Virginia Oral Health Coalition
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About the Center for Health Care Strategies
A non-profit health policy center dedicated to improving the health of lowincome Americans
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Medicaid’s Purchasing Power
Medicaid serves 70 million Americans
45% newborns 33% children
With Medicaid expansion, may serve more than 80 million
Many people with chronic illnesses and disabilities Many frail elderly
Poor health care quality is an issue for all Americans; however, the gap is substantially greater for Medicaid beneficiaries
As the largest purchaser of health insurance, Medicaid can leverage its purchasing power to: Access performance data Identify and address gaps in quality
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Focus of CHCS Oral Health Initiatives • Support state Medicaid agencies and stakeholders to advance oral health care access, utilization and quality for low-income children and adults. • Facilitate collaborative learning and provide direct technical assistance.
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Use of Dental Services by Medicaid-Enrolled Children • Dental care is fully covered by EPSDT, but fewer than half of Medicaid-enrolled children nationally receive any dental service each year, and even fewer receive a preventive dental service. • Rates of preventive dental service utilization have been increasing slowly, but vary widely by state – ranging from 21% in Ohio to 60% in Connecticut. • States that have achieved increases in utilization often grapple with how to improve beyond a certain point.
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Barriers to Oral Health Care Among MedicaidEnrolled Children • Inadequate: ► ►
►
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Number of Medicaid-participating dental providers
Willingness of dental providers to treat young children Transportation to appointments
Awareness of Medicaid dental benefits and oral health care guidelines
• Cultural barriers
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CMS National Oral Health Initiative • A 2010 to 2015 initiative with two goals: ►
►
Goal #1 – Increase by 10 percentage points the proportion of Medicaid and CHIP children ages 1 to 20 (enrolled for at least 90 days) who receive a preventive dental service. Goal #2 – Increase by 10 percentage points the proportion of Medicaid and CHIP children ages 6 to 9 (enrolled for at least 90 days) who receive a sealant on a permanent molar tooth.
• CMS continues to support states to improve access
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CHCS Medicaid Oral Health Learning Collaborative • Supported seven states working toward the two CMS national oral health goals
• Provided quality improvement concepts and tools, peer learning opportunities, and tailored technical assistance • Conducted all-state and individual state technical assistance calls and convenings
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Focus of State Aims to Advance Preventive Dental Service Utilization • Increasing the percentage of: ► ► ► ►
►
• • • •
Oral health providers delivering a preventive dental service Non-dental providers delivering fluoride varnish with a dental referral All children (or specific ages) who receive a preventive dental service Pregnant women ages 19-21 served by WIC who receive a preventive dental service Children who have a dental home
Reducing age of first dental visit Increasing use of alternative providers Improving rates and accuracy of billing and reporting Tracking referrals to dental care 19
Range of Interventions: Goal #1 Providers • Dental gap reports and peer comparisons • CE for online oral health training • Messages about oral health care in provider forums, mailings, calls • Reimbursement to PCPs for fluoride application • Incentives for provider performance and reporting; expanded office hours
Families/Members • Calls and letters to families with last dentist visited; help to schedule appointment • OBGYNs educate pregnant women about importance of oral health • Oral health messages in educational materials for pregnant women • Plan newsletters with oral health messages • Public service announcements in customer service hold times and social services waiting rooms 20
Focus of Aims to Support Goal #2 • Percentage of children ages 6-9 who receive dental services from a dental home
• Percentage of providers applying sealants to children ages 6-9 • Plan encouragement of sealant application • Number of schools with sealant programs • Percentage of children ages 6-9 receiving a sealant in a particular setting
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Range of Interventions: Goal #2 Providers • Required to serve as dental home • Incorporate messages about sealants in provider education • Train non-dental providers in sealant application • Educate school nurses on importance and availability of sealants • Allow hygienists providing services in public health programs to bill Medicaid
Families/Members • Assign members to dental home • Educate members about importance of sealants • Call members with no dental history to help schedule a dental visit
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Working Collaboratively with Managed Care: Arizona • State is contracted with 15 managed care organizations (MCOs) serving 90%+ of all Medicaid beneficiaries • MCOs provide: ►
►
►
Gap reports to providers of members who have not received a fluoride application Outreach to general and pediatric dentists through mailings, phone calls, and forums Provider education through online training
• AHCCS-conducted outreach to managed care dental directors, MCOs, and quality improvement staff • AHCCCS-driven dental work group, ongoing monitoring and oversight 23
Efforts to Increase Fluoride Varnish by NonDental Providers: Arizona • Policy change allowing reimbursement to primary care providers for fluoride varnish application
• Outreach to non-dental providers through mailings, phone calls, and forums • Monthly gap reports • Provider education through online training
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Takeaways from Arizona’s Efforts • Proactively let providers – both dental and nondental – know how they are doing.
• Use all methods of outreach available; what works for one entity may not work for another. • Policy changes to reimbursement are helpful as a means of incentivizing non-dental providers to apply fluoride varnish.
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WIC Pay-for-Prevention Project: New Hampshire • Services provided by a registered dental hygienist under public health supervision
• Dental clinics held at regular intervals, up to once per week • Referrals made to local dental offices • Three original pilot locations, currently operating in two
• Evaluation of return on investment for on-site treatment and referrals 26
Partnering with New Hampshire WIC • Oral health education messages from the dental hygienists and dental assistants align with WIC’s nutrition messaging: ►
Eliminate sugar-sweetened beverages
►
Reduce consumption of fruit juice
►
Eat more fruits and vegetables
►
Smoking cessation for pregnant women
• Quarterly visits by WIC-enrollees to local offices provide an opportunity to: ►
Reinforce dental hygiene
►
Provide preventive dental services on a regular basis 27
Takeaways from New Hampshire’s Efforts • Think out of the box – look for ways to bring dental care to high-risk populations
• Consistency is key • Identify partners within the community • Use messaging that is in-sync among the partners
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Pursuing Legislative Change: Minnesota • Focus on revision to Medicaid dental reimbursement and delivery system • Efforts began with stakeholder meetings resulting in a report to the legislature recommending: 1.
Increase base payment rates for dental services and refine the payment structure;
2.
Support an evidence-based, integrated service delivery system; and
3.
Improve administrative structures.
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Pursuing Legislative Change: Outcomes • The legislature requested the Department of Human Services to draft a legislative proposal ►
Stakeholders engaged to aid in crafting legislation
• Although unsuccessful in passing the full legislative package: ►
Rates for rural providers were increased
►
Teledentistry was added to the benefit set
►
The Department continues to work with stakeholders for further legislative change
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Takeaways from Minnesota’s Efforts • Sometimes it makes the most sense to focus on the bigger picture.
• Stakeholder involvement is critical, especially when working with lawmakers. • Stronger stakeholder relationships exist because of the process.
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Leveraging Existing Resources: Washington • Access to Baby and Child Dentistry (ABCD) ► ►
►
Recruit and train dentists Work with community organizations to identify eligible children and remove barriers to access Train primary care providers to deliver preventive services
• Inter- and intra-agency collaboration ►
Children’s Administration
►
Health Care Authority
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Leveraging Existing Resources: Washington • County coordinators work closely with dental champions, the dental society, and participating dentists to ensure eligible children are receiving necessary care • County coordinators: ►
Conduct outreach to organizations
►
Identify and enroll young children in ABCD
►
Match each child to a dentist
►
Outreach to clients under age 20 with no recent dental visit
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Takeaways from Washington’s Efforts • Utilize resources already available • Delegate work to those on the ground
• Actively pursue providers
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Collaborating to Improve Oral and Overall Health in Virginia Katherine Libby Program Director Virginia Oral Health Coalition December 15, 2015
Overview • Background • Setting the stage for collaboration in Virginia • Examples of collaborative efforts and some results • Key takeaways
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Virginia Oral Health Coalition Striving to integrate oral health into all aspects of health and wellness through advocacy, education and public awareness Individuals and organizations from wide range of issue and stakeholder groups work together to lift up issues, identify solutions and enact change
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Backbone organization convenes, coordinates, communicates and drives
Shared problem solving, implementation and strategies promotes change
Setting the Stage - Key Partners and Activities • VaOHC, Medical and Dental Collaboration Initiative • DentaQuest, LLC, Early Dental Home (EDH) pilot project • Virginia Department of Health, Bright Smiles for Babies • Department of Medical Assistance Services (DMAS), Oral Health Learning Collaborative
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What do you notice about each of these organizations?
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Overarching Goal: Improve access to and utilization of oral health care services for Smiles for Children enrollees Targeted: Increase the number of children receiving oral health prevention services in medical primary care and that have a dental home by age one Targeted: Increase the number of pregnant women enrolled in Medicaid and FAMIS MOMs receiving dental services
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Expanding The Network • “Traditional” stakeholders – Public health dental professionals – Dental safety net
• “Non-traditional” stakeholders – – – – – – – – – – 43
Medical providers Academic institutions Provider associations Department of Social Services Women, Infants, and Children program Headstart Home visitors Childcare workers Managed care organizations Grassroots organizations
Aligning Activities and Stakeholder Groups • • • •
Medical Dental Collaboration Task Force Early Dental Home Group Pediatric Champions “Data and Strategies” Team – OHLC core group – DMAS – DentaQuest – Virginia Department of Health – VaOHC
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Part of it all!
Collaboration At Work - Example • Increasing oral health prevention activities and dental referrals in pediatric primary care – – – –
– – – –
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Survey about oral health practices in pediatric practices Meetings with pediatric providers (‘focus groups’) Creation of local ‘champions’ position In office trainings, group education at conferences, grand rounds Dissemination of dental referral tools, strategies and program information Toolkits for providers Utilizing data to target strategies, learn and guide future efforts (e.g., examining disparities) Developing best practices
Collaboration At Work - Example • Increasing the number of pregnant women enrolled in Medicaid and FAMIS MOMs receiving dental services – Early Dental Home Work Group • Disseminate information about oral health and dental benefits • Identify opportunities for education for non-traditional stakeholders • Think creatively about other opportunities for outreach 46
Collaboration At Work - Results • Increased number of non-dental providers billing for fluoride varnish • Established 2 pediatrician and pediatric dental provider champion teams (Richmond, Roanoke) – Facilitating education and training in local community
• Delivering information, education and training to non-dental providers in a variety of settings – (e.g. School Nurses Association, American Academy of Pediatrics Virginia Chapter Board, Independent Practice Association meetings)
• Electronic oral health in primary care toolkits – all information in one spot! • Using data to target outreach to providers
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Collaboration At Work - Results …less tangible, but equally important!
• Providers contacting us for more information about oral health and fluoride varnish trainings • Department of Social Services request for online learning modules for childcare workers • Core group members often perceived as being from the same organization • Relationships leading to new or expanded opportunities 48
Why It’s Working • Diversity of partners – expanded reach • Activities are mutually reinforcing work toward common goal • Helps overcome organizational/capacity limitations • Maximizes limited resources • Relationships are sustainable (and often free!)
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What It Looks Like • Continual communication and information sharing – One-on-one, through project teams, workgroups (Early Dental Home, Champions planning, etc.)
• Cross promotion, education and outreach – tag team! • Scheduled, regular meetings • Periodic assessment of current activities, gaps, opportunities • Stakeholder engagement and outreach 50
What It Takes • Dedicated time to relationship development and building trust • Understanding limitations • Communication • Support, individually and as organizations • Openness
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Takeaways • Involved leadership • Collaborative structure – driving force behind sustainability • Understand individual and organizational focus areas and limitations – create partnerships that fill gaps • Communication is key • Time spent engaging new stakeholders, building relationships, and learning about what they are doing is time well spent! 52
If you want to go fast, go alone. If you want to go far, go together. African Proverb 53
To Summarize… • What works for one state, may or may not work for another and depends on factors such as: ► ► ► ►
Geography Demographics Payment system Resources – financial, human, and otherwise
• There are many ways to improve utilization by addressing barriers on a small or large scale • Actively pursue and engage stakeholders, fostering new and existing relationships 54
To Summarize… • Engage leadership in state departments, as well as community organizations • Communicate with a wide range of stakeholders • For more information about approaches to advancing oral health for children served by Medicaid, visit www.chcs.org.
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Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
Contact Information • Stacey Chazin, MPH, CHES • schazin@chcs.org
• Jessica Lipper, MSJ • jlipper@chcs.org
• Katherine Libby
• klibby@vaoralhealth.org
• Tyler Brown
• tyler.brown@oralhealthamerica.org