The Role of Community Health Workers in Oral Health

Oral Health America Webinar Series

The Role of Community Health Workers in Oral Health

March 19, 2018

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Joan Cleary, MM Executive Director Minnesota Community Health Worker Alliance

Adele Della Torre, DDS Founder & Board Chair Ready, Set, Smile

Overview of the CHW Field Oral Health America Webinar March 19, 2018

Joan Cleary, M.M., Executive Director Minnesota Community Health Worker Alliance

Presentation Outline

• About the MN CHW Alliance

• Community Health Worker (CHW) Role: An emerging profession in oral health • Resources

About the Alliance Catalyst, convener, go-to resource, partner, consultant We’re a broad-based statewide partnership of CHWs and stakeholder organizations, governed by a voluntary nonprofit board.

Our Vision

Equitable and optimal health outcomes for all communities

Our Mission

Build community and systems’ capacity for better health through the integration of community health worker strategies

\

www.mnCHWalliance.org

What are we trying to accomplish?

Reduce Health Inequalities

Advance Triple Aim Full Integration of CHWs in MN Systems of Care

Adapted from NM Department of Public Health presentation

Our Focus

• Increase awareness of CHW role and best practices in advancing health equity, the Triple Aim and health care workforce diversity • Provide leadership and build capacity for the comprehensive adoption of CHW strategies in health care, public health & social services settings to reduce health disparities

• Strengthen and broaden access to statewide, competencybased CHW training, cont education, inter-professional education and research • Expand the reach and positive impact of CHW strategies through public and institutional policy change • Grow statewide partnership as well as exchange field-building info with other states and advance work at national level

CHW Definition A Community Health Worker (CHW) is a trusted frontline health professional who applies his or her training and unique understanding of the experience, language and/or culture of the populations he or she serves in order to carry out one or more of the following roles: • Providing culturally-appropriate health education, information and outreach in a variety of settings such as homes, clinics, hospitals, schools, shelters, local businesses, and community centers; • Bridging/culturally mediating between individuals, communities and health and human services, including actively building individual and community capacity; • Assuring that people access the services they need; • Providing direct services, such as informal counseling, social support, care coordination and health screening; and • Advocating for individual and community needs.

American Public Health Association CHW Definition The Community Health Worker (CHW) is a frontline public health worker who is a trusted member of or has an unusually close understanding of the community served.

This trusting relationship enables the CHW to: •Serve as a liaison/link/intermediary between health/social services and the community •Facilitate access to services •Improve the quality and cultural competence of services delivered.

For more info, visit: https://www.apha.org/apha-communities/membersections/community-health-workers

Distinctions between CHWs and other health professions • Do not provide clinical services

• Generally do not hold a license in another health discipline • Expertise found in shared life experience and/or culture with the populations served • Many spend significant part of their jobs working in home and community settings such as schools • Include focus on psychosocial needs and the social determinants of health, upstream and downstream

CHWs are uniquely equipped to advance health equity and the Triple Aim (better outcomes, increased patient satisfaction, lower costs) They typically reside in the communities they serve, and share the same language; ethnic, cultural and educational background; and/or life experience.

Reducingfrom Adapted Ethnic/Racial NM Department AsthmaofDisparities Public Health in Youth presentation (READY) For more information, visit: successwithchws.org/asthma

An Emerging Workforce

CHWs Tribal CHRs Lay Health Advisors Promotores(as) Patient Navigators Community Health Advocates

Adapted from NM Department of Public Health presentation.

Community Educators Care Guides Outreach Workers

Recognized by Leading Public and Private Authorities • American Public Health Association (APHA) • Centers for Disease Control (CDC) • Center for Medicare and Medicaid Services (CMS) • Community Preventive Services Task Force

• Health Affairs • Health Resources and Services Administration (HRSA) • Institute of Medicine (IOM) • Institute for Clinical and Economic Review (ICER) • U.S. Dept. of Labor Standard Occupational Classification (DOL) • Minnesota Department of Health

• Twin Cities Medical Society

What are We Learning from Recent CHW Studies on Return on Investment?

Net Return Carl Rush, “CHWs: A National Perspective,” Indiana CHW Coalition Community Symposium, 10/15/2012

Minnesota CHW Building Blocks

Payments Under Minnesota Health Care Programs Statewide Standardized Competency Based Curriculum

Scope of Practice

CHW Education in Minnesota First state in US with statewide standardized CHW curriculum based in higher education

• Model competency-based curriculum including internship

• Offered by network of 7 post-secondary schools • Online and in-person formats available • Credits provide educational pathway to college degree and other health careers • Leads to certificate recognized by the Minnesota Dept of Human Services (DHS) • Continuing education available and ongoing employer-based professional development • Over 650 CHW Certificate Holders • Curriculum includes oral health module

Current CHW Coverage under Minnesota Health Care Programs (Medicaid in Minnesota) • Diagnostic-related patient self-management and education services under fee-for-service and managed care • Face-to-face services, individual and group • Signed diagnostic-related order for patient education in patient record

• Requires clinical supervision by authorized provider types including dentists • Standardized education curriculum consistent with established or recognized health or dental care standards • Provide service in clinical setting, home or community; document services provided • Fluoride varnish application by CHWs is also covered • For more on coverage, contact: Susan.Kurysh@state.mn.us

Challenges and Opportunities Drivers of CHW Integration • Increasingly diverse and rapidly aging population

• ACA increasing access to thousands of previously uninsured with projected primary care shortage • Focus on Triple Aim and team-based care • Payment shift from fee-for-service to value-based purchasing and total cost of care • Incentives and penalties under health reform • Greater emphasis on performance measurement and reporting by race, ethnicity, preferred language and country of origin, statewide and by region • Health equity growing in priority • Recognition of the impact of social determinants of health

Success with CHWs: Oral Health Road Map Report by Minnesota CHW Alliance http://mnchwalliance.org/oral-health-road-map/

• Outlines needs and gaps that oral health CHWs address

• Spotlights successful examples of oral health CHWs working on teams different settings…dental clinic, school-based program, hospital emergency department and nonprofit focused on coverage • Identifies opportunities and next steps for CHW integration • “CHWs are a perfect bridge between patients and providers, medical and dental. Oral health and overall health go hand-inhand, and CHWs are an ideal way to tie them together.” – Twin Cities dental care provider Payment shift from fee-for-service to value-based purchasing and total cost of care • “The dental community health worker is integrated into clinic operations. She works with every other provider daily. We need a fleet of CHWs.” Greater Minnesota dental provider • Funded by Delta Dental of Minnesota

CHW Roles: Oral Health Care Coordination • Client engagement and activation • Assessing individual strengths and needs • Addressing barriers and connecting to services • Promoting oral health literacy and self care • Coaching and motivational interviewing • Helping clients and their parents/caregivers understand and prepare for oral surgery

• Coordinating medical, insurance and community referrals and follow-up • Sharing feedback and cultural expertise/community knowledge with health team • Helping clients navigate complicated health and social systems • Example: Oral Health CHW at Emergency Dept at Hennepin County Medical Center, Minneapolis

CHW Roles: Oral Health Education

• Providing culturally- and linguistically-appropriate information

• Teaching health promotion, prevention and disease management • Coaching and motivational interviewing • Modeling behavior change

• Promoting health literacy and self care • Promoting treatment adherence • Leading patient education groups • Examples: Ready Set Smile, Minneapolis and Community Dental Care, St. Paul

CHW Roles: Oral Health Outreach and Referral

• Case-finding and recruitment

• Home visiting • Promoting oral health literacy and self care • Screenings • Connecting to primary care, mental health and other services • Preparation and dissemination of materials/communications • Advocacy and community engagement • Community needs assessment • Example: NorthPoint Health and Wellness, Minneapolis

CHWs Address the Social Determinants of Health

Adapted from Dahlgren and Whitehead, 1991

CHWs Bridge Clinical and Community Settings

Selected Resources CDC CHW Toolkit.2015:whttp://www.cdc.gov/dhdsp/pubs/chw-toolkit.htmw Community Preventive Services Fact Sheet on CHWs: http://www.thecommunityguide.org/cvd/OnePager-CHW.pdf ww.bcbsmnfoundation.org/system/asset/resource/pdf_file/26/CHeport_10.pdf Institute of Medicine, Bringing CHWs into the Mainstream of Health Care, 2015:http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/Wkfrce3_CHW_IO M_Paper.pdf

MN CHW Alliance Website: ww.mnchwallliance.orgwww.mass.gov/dph/communityhealthworkers MN CHW Alliance, Oral Health Road Map for Community Health Workers, 2016. http://mnchwalliance.org/oral-health-road-map/ http://mnchwalliance.org/wp-content/uploads/2012/12/Oral_Health_Road_Map_FINAL.pdf Rural Health Information Hub, Regional Oral Health Pathways, 2017. https://www.ruralhealthinfo.org/project-examples/815 State of MN CHW Tool Kit, 2016. http://www.health.state.mn.us/divs/orhpc/workforce/emerging/chw/2016chwtool.pdf Wellshare International, Summary Report on Perspectives on the (MN) CHW Workforce:, 2015: www.welllshareinternational.org ://www.ncbi.nlm.nih.gov/pmc/articles/PMC3343233/ Wilder Foundation, Experiences of CHW Employers, Nov 2015: http://www.health.state.mn.us/divs/healthimprovement/content/documents/CHWEmployerRepo rt1115.pdf

Thank you!

For more information, please contact: Joan Cleary, M.M., Executive Director Minnesota Community Health Worker Alliance joanlcleary@gmail.com

www.mnCHWalliance.org www.successwithCHWs.org/asthma www.successwithCHWs.org/mental-health

March 19, 2018 - Oral Health America Webinar

Mission Statement: Ready Set Smile Ready Set Smile prepares and empowers all children to care for their oral health through onsite school based clinics and education. We believe that with preventive services and a caring environment, all children can be free of dental disease.

Adele Della Torre DDS Founder & Board Chair • RDH - Bergen Community College 1975 • DDS - Columbia University School of Dental & Oral Surgery 1981 • Founded ADT Dental 1989 • Activist/Advocate of Social Justice 1999 • Founded Ready Set Smile 2013

Founding History of RSS by ADT Dental • American Dental Association's Foundation establishes a nation-wide event: Give Kids A Smile (GKAS)

• ADT Dental participates since its inception through one local elementary school, Jefferson Community School

• Great Recession Hits and Jefferson becomes a Minneapolis Public School for immigrant students - needs of children become overwhelming

The Timing was Right in 2012! • Affordable Care Act Triple Aim: improve the experience of dental visit improve oral health improve cost per capita

• Dental Therapist: Minnesota legislated licensure of a midlevel dental practitioner

Why Minnesota Medicaid kids do not see a dentist?

• Minnesota is far behind! CMS reported that only 37% of children on Medicaid see a dentist once in given year. The average for other states: 67%.

• Minnesota is 49th in the nation for reimbursement rates for children's dental services

• Families cannot find clinics willing to take their child's insurance • Low-resourced families face barriers to care: time off work, transportation, cultural fears, fear of cost, history of bad experiences

4 Essential Facts about the Childhood Disease of Dental Caries 1. Dental caries is the most prevalent chronic disease affecting school age children

2. 85% of the dental decay occurs in 15% of the children 3. Our baseline data: 47% of the children have untreated decay!

4. This disease is 100% preventable

Break the Chain of The Disease 1. School-Based Program portable clinics

2. Employ Allied Professionals 3. Provide Preventive Services and Atraumatic Caries Control

4. Classroom education 5. We become part of the culture of the school

We go to the kids!

Jefferson Community School

Loring Community School

Stonebridge World School

How do we accomplish our goals?

Community Health Workers 1. Classroom Educators – 8 modules with hands on activities

2. Attend after-school events to interface with families

3. Serve as our assistants and scribes in the clinics 4. Liaisons to the parents, teachers, school nurses and social workers

5. Case managers

Reflect the community served

Community Health Workers teach the kids!

RSS is integrated into the school culture Resource to the school nurses and social workers Interact with teachers, cafeteria workers, custodians

Set up tables for conference days Participate in carnivals, family nights, health fairs

Some of Our Educational Messages Rethink your drink Don’t rush the brush Floss like a boss Stop the pop

In our preschools, CHWs educate the parents

• Serving 5 preschools & one homeless shelter •

12 different lessons for parents of infants, toddlers • Dental services for kids & education for the kids and their parents

Deliver Dental Services

Ready Set Smile: The Clinic Process 1.

iPad – Data tracking system

2.

Routine Preventive Services: Toothbrush Prophys, Fluoride Varnish Application (FVA), Sealants

3.

Atraumatic Caries Control -Silver Diamine Fluoride -Interim Therapeutic Restorations

4.

Caries Risk Assessment (CRA)

5.

Based on CRA, a 3rd FVA placed by Community Health Workers during the school year.

Community Health Workers and Fluoride Varnish • CHWs are non-dental health workers They cannot provide FVA in our dental clinics.

• Minnesota Department Of Human Services (DHS) provides a certificate for CHWs to place FVA • Children with high or moderate caries risk, receive an additional FVA in the hallways of our schools.

Oral Health Curriculum for Community Health Workers Our Community Health Workers require intensive on-the-job training Trainings are available aimed at other dental health care providers, but do not fit our needs.

We are in the process of developing 15 modules for training of Oral Health CHW Specialists - Biology of Caries

- Fluoridated Water

- Motivational Interviewing

- Arresting Agents: SDF & ITR

- Oral Health and Nutrition

- Preventive Services: FVA & Sealants

iPad – Data Tracking System

We can track the health of every tooth, in every student.

iPad – Data Tracking System • • • •

Tracks all our data securely Tracks changes over time Maintains our records Prints letters to parents in their home language for each visit

A Call to Action: At Baseline – 47% of Students Have Untreated Decay!

Before Treatment

60%

Percentage of Students with Untreated Decay

45%

30%

15%

0% Jefferson Community School

Loring Community School

Sojourner Truth Academy

The Family Partnership

Total

Initial Success of RSS: A Decrease of Students with Untreated Decay Prevalence of Untreated Decay Dramatically Decreases Over Time

Percentage of Students with Untreated Decay

80%

65%

Jefferson Community School Loring Community School Sojourner Truth Academy

50%

35%

20% 2H 2013

1H 2014

2H 2014

1H 2015

School Semester

2H 2015

1H 2016

Effects of RSS in Students Who Remain in the Program Prevalence of Untreated Decay decreases with Number of Visits

Percentage of Students with Untreated Decay

60%

45%

Jefferson Community School Loring Community School Sojourner Truth Academy

30%

15%

0% 1

2

3

4

5

Students with 1 visit, 2 visits, 3 visits, 4 visits, 5 visits, 6 visits

6

Advanced Dental Therapist • Analogous to Nurse Practitioner/Physician Assistant • ITR- Interim Therapeutic Restorations • Silver diamine fluoride treatments • Does not require a dentist on site

Collaborative Dental Hygienist • Oversees our clinics and schedules • Provides our preventive dental services: prophy, fluoride, sealants, SDF, selfcare.

• Collaborative agreement- not required to have a dentist be onsite.

Stories After

Before

Value to the Greater Community • • • • •

Reduced missed school days Cost of ER visit: $400 - $500 Cost of OR time: $8,000 - $10,000 Breaking the culture of fear Creating adults who will value relationships with healthcare providers

Ready Set Smile Goals for 2018 Our program is scalable!

We have many requests from schools who want our program.

How do we sustain ourselves?

1. Medicaid insurance supports 25% of our budget (38% of our patients are uninsured) 2. Foundations: Delta Dental Foundation, Otto Bremer Trust, Medica Foundation, Giving WoMN, Hats & Mittens, Rose Francis Foundation, Nara Foundation, Walker Foundation, Henry Schein, Buuck Family Fund, Gilligan Family Fund, Minnesota Dental Foundation, Schulze Family Foundation (40% of our budget) 3. Private Philanthropy, Corporate Donations from Private Dental Practices (35% of our budget)

Reaching our Goals 1. Our goal is NOT comprehensive care through drilling and filling.

2. Our goal is to break the cycle of the disease with:

awareness prevention 3. The Triple Aim

sound relationships education

Thank You! www.readysetsmile.org

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.

CE Credit Available

Contact Information • Joan Cleary • joanlcleary@gmail.com • Adele Della Torre • adellatorre@readysetsmile.org • Eamari Bell • eamari.bell@oha-chi.org