1. Iowa Plan: Dental Public Health in Iowa
Bob Russell, DDS, MPH
Iowa Department of Public Health

2. Title V MCH Service Areas

3. Partners
Within each county are multiple agencies (local public and private/non-private agencies) that serve families:
County health departments
Public health nursing services
Home health care agencies
Visiting nurse services
Community action programs 3

4. Assessment Examples Open Mouth Surveys Medicaid Services
Title V Databases & Reports
Public Health Supervision Reports
Back to the three core functions of public health…
In order to assess programmatic and policy needs - We monitor oral health status and prevalence of disease several ways.
One thing that we do is to work with our contractors to conduct open mouth surveys. Our funding dictates that we primarily focus on children – and specifically a National Performance Measure for the Title V block grant requires determining prevalence of sealants on 3rd graders. These surveys are conducted as often as needed – based on statistical significance of results. Survey reports are posted on the IDPH Web site.
We are also beginning to conduct more surveillance on children younger than school age – between 0 and 5. Two years ago we did an open mouth survey of Head Start children. Last year we collected information on children in WIC. This year we plan to go into day care centers.
We also review Medicaid data – usually utilization and billing data. By looking at the ability of Medicaid-enrolled children to access services, we can assess the ability of at-risk children and families in general. It also provides us a means to determine if our programs are making an impact.
We are also able to request specific reporting from Medicaid – which helps us to look at specific issues – for example, physicians who bill for fluoride varnish applications – where they are located, how many they did. These things help us to determine program needs and potential policy changes needed.
Another means of assessment includes reviewing information from databases for our MCH Contractors – which track demographics, services provided (as well as barriers and needs) of CH and MH clients.
We also receive annual reports from dental hygienists practicing under public health supervision – which provides a glimpse at the number of services and population who receive care via public health settings.
There are other things we can use – such as the Behavioral Risk Factor Surveillance – BRFSS – and Iowa’s House hold Health survey. Our assessment function does not include RESEARCH – which is something more applicable to the University.

5. National Trends in Caries-Free Schoolchildren – Permanent Teeth
Fluoridation and Public Health
2011 Training Program
National Trends in Caries-Free Schoolchildren – Permanent Teeth
Ages 5-17 years
Ages 6-19 years
Similarly, the percentage of caries free children has been increasing.

6. Iowa: Untreated decay is decreasing

7. Iowa: Adults

8. Penetration of Public Health Sealant Programs in Iowa
79 elementary schools
Total: 990 elementary schools
21 Junior High Schools
Total: 299 Junior High Schools
9,941 Sealant placed on 1st molars in
2,381 sealants placed on second molar teeth

9. Decay Positive and Decay Negative
We subset the dataset into two datasets: decay positive and decay negative. The graph demonstrates how the treatment rate differed between decay and no decay treatment groups. This shows that there is a possibility that the screenings do play some role in children seeking treatment.
Decay Positive and Decay Negative

10. Results Decay Positive Decay Negative 29.9% from East Central Iowa
29.1% Rural (Not adjacent to urban)
66.7% white, 16% unknown race/ethnicity
80.5% spoke English
92.2% had a Medical Home
69.3% had a Dental Home
52.7% Males
56.8% were younger than 5
37.8% from East Central Iowa
22.2% Rural (Not adjacent to urban)
70.5% white, 16% unknown race/ethnicity
85.2% spoke English
95.5% had a Medical Home
61.2% had a Dental Home
49.9% Males
73.5% were younger than 5
We used logistic regression analysis to find associations between variables and outcome of not receiving treatment.
In CAReS, Medical and Dental Home are both determined for a child, based on responses to specific information from the parent or guardian. So, as you see on this slide, for the purposes of determining medical and dental home in CAReS:
Medical home: child has a usual source of medical care, the care is available 24/7, and the source of the care maintains the child’s record
Dental home: the child has a usual source of dental care, that source of care maintains the child’s record, and the child has seen a dentist within the past 12 months

12. Iowa: a State in Transition
Demographic Trends
Rapid Ethnic Diversification
Aging white population
Low fertility rates among whites
Exodus of graduates to other states
Higher birth rates among native minorities
Large influx of immigrants, primarily
Latinos, to work in labor shortage

13. Iowa Implications of Changing Demographics
Need for increased outreach services
Need for new service hours
Child Care barriers
Geographic and transportation barriers
Different health care utilization patterns

15. Iowa Elderly in Assisted Living Centers
2007 Survey Results

16. The Iowa Picture
We have stated that 92% of Iowans are receiving optimally fluoridated water. What does this % really mean?
 92% of Iowans who receive their water from a Community Water Supply are receiving optimally fluoridated water.
 Overall, approximately 83% of Iowa’s total population is receiving optimally fluoridated water. 
This percentage may actually be higher depending on if the population who receives their water by a private well has naturally fluoridated water or is adding fluoride to their water.
We have no system for tracking private wells or monitoring leaving over 248,205 estimated Iowans potentially lacking fluoridated water!

17. Trends are Troublesome
No longer provides fluoride
Water System
County
Ashton
Osceola County
Columbus Junction
Louisa County
Coon Rapids
Carroll County
Elkader
Clayton County
Everly
Clay County
Floyd
Floyd County
Fort Madison
Lee County
Granger
Dallas County
Maxwell
Story County
Sac City
Sac County
Sanborn
O’Brien County
Sutherland
Victor
Iowa County

18. Considering discontinuation or reduction
Iowa
Considering discontinuation or reduction
Water System
County
Aplington
Butler County
Cedar Rapids
Linn County
Dallas Center
Dallas County
DeSoto
Gilmore City
Humboldt County
Granger
Keokuk
Lee County
Mechanicsville
Cedar County
New Sharon
Mahaska County
Ossian
Winneshiek County
Tama
Tama County

19. I-Smile An Overview of Iowa’s Dental Home Initiative for Children
Bob Russell, DDS, MPH
State Public Health Dental Director
Iowa Department of Public Health

20. 2005 Legislative Mandate
By July 1, 2008, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive care identified in the oral health standards under the EPSDT program.
In response, the Iowa DHS partnered with the IDPH, the IDA, the IDHA, the University of Iowa, and others to develop a proposal that would fulfill the dental home mandate.
The result is the I-Smile dental home project.

21. Iowa Legislative Mandate Modified
By December 31, 2010, every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the EPSDT program.
2010 has come and gone, but the mandate is still in effect.
* Language modified in 2008, HF2539 21

22. Conceptual Dental Home
The dental home is a system that allows all children, even those often excluded from receiving dental care, to have early and regular care to ensure optimal oral health.

23. The I-Smile Dental Home
DENTIST
NURSE
PHYSICIAN
DENTAL
HYGIENIST
What makes I-Smile unique is the way that we envision the dental home.
The I-Smile dental home is not a dental office.
It is envisioned as a conceptual dental home.
Uses a team approach to manage oral disease
Primary prevention and care coordination are a large focus
Dentists provide treatment and definitive diagnosis
Other health care professionals are part of a larger network – providing oral screenings, education, anticipatory guidance, and preventive services as needed 23

24. I-Smile Objectives Improve the dental support system for families.
Improve the dental Medicaid program.
Implement recruitment and retention strategies for underserved areas.
Integrate dental services into rural and critical access hospitals.
The original plan for implementing I-Smile identified 4 objectives.
The first objective, improving the support system for families, is the one with the most impact on our existing public health system – specifically the state’s Maternal and Child Health system – and is the one that I will focus on.

25. I-Smile Strategies Partnerships and planning
Link with local board of health
Provide training for child health agency staff
Develop agency oral health protocols
Provide education and training for health care professionals
Ensure completion of screenings and risk assessment
Ensure care coordination services
Ensure provision of gap-filling preventive services
Each contractor must submit an action plan and budget, developing activities based on these strategies as well as based on their local needs and assets.

26. Improve Dental Support System for Families
Strengthen Iowa’s Title V MCH System
Establish a dental hygienist within each Title V Child Health agency as the local I-Smile Oral Health Coordinator
Currently, Iowa has 24 dental hygienists working as regional I-Smile™ Coordinators
They create a system to assure optimal oral health for children.
Work on this objective occurs through our state’s Title V Maternal and Child Health system.
The Dept of Public Health has 22contractors – private/non-profit or public agencies – to implement the Title V child health program at the local level. Contractors are responsible for assuring health services for pregnant women and children.
For several years, the Department of Public Health and the Department of Human Services have had an interagency agreement. The agreement allows IDPH to assist in achieving EPSDT standards through these contractors – and also allows the contractors to bill Medicaid for limited services provided to Medicaid-enrolled clients.
This has also been the means for funding Iowa’s ABCD program. Using lessons learned from our ABCD program, we were able to develop I-Smile strategies to be implemented through our local MCH contractors – now also funded through the interagency agreement.

27. I-Smile Referral System

28. Medicaid, uninsured, and underinsured children from birth-12 years
I-Smile Dental Home Care Plan Diagram
I-Smile
Oral Health Coordinator
Oral Screening and Risk Assessment
Preventive Care
Education
Medicaid, uninsured, and underinsured children from birth-12 years
Level Level Level 3
Low Risk
No observable disease
Moderate Risk
No observable disease
High Risk
Observable disease
High Risk
Severe
disease P L A N
Care coordination
Referral for dental exam within 1 year
Oral screening, risk assessment, and preventive care in 6 months
Referral for dental exam within 6 months
Oral screening, risk assessment, and preventive care in 3-6 months
Referral for dental exam within 3 months
Oral screening, risk assessment, and preventive care in 3-6 months
Care coordination
Immediate referral to dentist/specialist
Oral screening, risk assessment, and preventive care in 3 months

32. Based on SFY2012 Medicaid paid claims, Iowa Department of Human Services
In 2012:
More than 1 ½ times as many children ages 0-12 saw a dentist for care than in 2005
3 ¾ times as many children ages 0-12 received care from a hygienist or nurse working for a Title V agency than in
61 % of children ages 3-12 saw a dentist

33. I-Smile--Challenges
Still too many children under the age of 3 who do not receive dental services.
Lack in dentists willing to see the very young child.
Low participation by dentists willing to see Medicaid children.
Low Medicaid reimbursement.
Decreasing and aging dental workforce
Mal-distribution of available dental providers
Iowa Facts:
Decreasing and aging dental workforce
Increasing number of health professional shortage sites
Mal-distribution of available dental providers
Along with low reimbursement rates, the other barriers to treatment for our children include a shortage of dentists.
Dentists in Iowa are aging, the average age is 55, with retirements and fewer dentists staying in Iowa after graduation from dental school the numbers are project to decline.
Of the dental workforce only 2% are pediatric dentists and they are located in the major metropolitan areas. General dentists are reluctant to see children, especially those under age 3.
All of this background just goes to show you how important your role is when it comes to educating parents and reducing the risk of dental problems among our low income population. Poor kids are more likely to have dental problems therefore education and preventive services are their best defense against future problems!!

34. I-Smile--Sustainability
Promote children’s oral health to parent’s and caregivers.
Support gap-filling preventive services within public health and Title V agencies.
Maintain partnerships with early childhood programs.
Share information with stakeholders in anticipation of a changing health care system within Iowa.
Continue to support “health homes” by collaborating with medical providers to include oral health as part of well-child care.
Explore funding and collaborative opportunities with private organizations so that oral health becomes a priority statewide.
Because children see their physician more during the years before age 3 and dentists are still reluctant to see young children physicians are being trained to do a more thorough oral evaluation during the well child exams. Medicaid is also paying for fluoride varnish application in the physicians office.
I-Smile Screening Guide
Basic Oral Health Screening Instructions
I-Smile Coordinator Office “Lunch and Learn” sessions
Web-based training with CMEs
Peer-to-Peer study groups

35. I-Smile™ Future Good oral health for all children beginning at birth
Long-term savings in dental care costs
Improved overall health of Iowa children and adults

36. Dental Screening Requirement
(became effective July 1, 2008)
A critical step in “closing the gap” in access to care for underserved children
Since 2008, Iowa children newly enrolling in elementary and high school must provide evidence of having a dental screening or exam.

37. Dental Screening Requirements
Elementary school
Prior to age 6, but no earlier than age 3
Licensed physician, physician assistant, nurse, dental hygienist, dentist
High School:
Within one year of enrollment
Licensed dental hygienist or
dentist

38. Integration with I-Smile™
What if a child has a problem getting a screening?
What if a problem is detected and a child doesn’t have a dentist?
Contact local I-Smile Coordinator

39. Supervision
Dental hygienist providing direct care services in Iowa must work under the supervision of a dentist. In public health settings, this would be either public health or general supervision.

40. Public Health Supervision
Recommended by IDPH, this allows hygienists working in a public health setting to provide services without the patient first being examined by a dentist.
*Dentists providing public health supervision are not required to provide future dental treatment to patients served by the hygienist.

41. Some services required to maintain Public Health Status:
Requirements for Practice as a Public Health Supervision Hygienist (PHSH)
Educational & Experiential Requirements
An Active Iowa license and a
Minimum of 3 years clinical experience
No special educational requirements
Must collect data on services provided
Must have procedure for maintaining records
Practice Settings Available to a PHSH
Schools
Head Start
FQHCs
Public Health Dental Vans
CHCs
Nursing facilities
Free Clinics
State/local federal public health programs
Day Care Centers
Services a PHSH can Provide
Assessments
Screenings
Data collection
Educational, diagnostic, preventive and therapeutic services defined in the rules
May NOT provide local anesthesia or nitrous oxide.
Requirements
Settings
Services
Some services required to maintain Public Health Status:

42. Statutes & Rules Applicable Forms
Practice as Public Health Supervision Hygienist–
What Else Do I Need to Know?
Statutes & Rules
Applicable Forms
State Dental Practice Act
Iowa Code 153
Iowa Code 147
Iowa Code 272C
Dental Board Rules
Public Health Supervision
(PHS Application)
PHS Reporting Form
Iowa Dental Board

43. General Supervision
A dentist is required to see a patient prior to a dental hygienist providing certain services under general supervision
Sealants
Prophylaxis
Radiographs

44. Public Health Supervision
Currently, a hygienist must have an Iowa license and a minimum of three years of clinical experience to work under public health supervision.
*Language removed April For certain services (ie: prophy’s, sealants, and radiographs), there is no longer a period of time, no more than 12 months, in which an exam by a dentist must occur prior to providing this service to a patient again.

45. Loan Repayment Two options:
National Health Service Corps – federal program
State Loan Repayment Program (called PRIMECARRE)
Site criteria:
For PRIMECARRE, must be public or non-profit; NHSC also allows for-profit
Federal Health Professional Shortage Area (found at
Sliding fee scale, accept Medicaid and Medicare

46. Applicant Eligibility
Full-time or half-time (meet definition)
U.S. citizen
Education-related debts
No unfulfilled practice obligation to federal, state, local government or other entity (such as employer)
Certification or license to practice in Iowa
Serve all patients regardless of ability to pay
Full time = 40 hours
Half time = 20 hours
Cannot do both loan repayment programs at the same time (but can do them back to back)
Cannot have any other contractual obligation at the same time (employer contract)

47. Eligible Professions Primary care physician Dentist Dental Hygienist
Physician Assistant
Nurse Practitioner
Certified nurse Midwife
Clinical Psychologist
Clinical Social Worker (LISW only)
Psychiatric nurse specialist
Mental Health Counselor
Marriage and Family Therapist
For health care providers providing DIRECT CARE!!!
Private practice dentists would not qualify (they are not public/non-profit).
For RDH’s they would have to work for an FQHC or other type of public health dental clinic.

48. Both Programs: Clinician must be: working in a federally designated HPSA, US citizen, qualified student loan debt, cannot be fulfilling another obligation at the same time
NHSC
PRIMECARRE
Online application,
Application cycle once per year available on IDPH website, Current due date: October 24, 2012
Federally Administered
State Administered
All Federal Funds
1:1 State/Federal Funds
Requires Site Application
Does not require site application
Full time 2-year contract $60,000 Half time 2-year contract $30,000
Half time 4-year contract $60,000
Full time 2-year contract up to $100,000 or Half time 2 –year contract up to $50,000 (depending on availability of funding and number of applicants)
Competitive Process based on HPSA scores
Competitive Process with review committee
Can be For-Profit, Non-Profit, or Public Sites
Only Public or Non-Profit Site
Entire amount of funding provided to clinician at beginning of 2-year contract with NHSC
Half of funding provided at the beginning of each year of the 2-year contract; funds go directly to lender
One-year continuations
Can re-apply in two-year increments
Comparison of the two programs:
Applicants must be licensed by January 1 (date the contract starts)
14 typically apply
5-8 typically awarded

49. Thank you! Iowa Department of Public Health Oral Health Center
Dr. Bob Russell, DDS, MPH
Public Health Dental Director
(515)
Iowa Department of Public Health
Oral Health Center
Lucas State Office Building
321 East 12th Street
Des Moines, Iowa 50319

50. References
Institute of Medicine, National Academy of Sciences. The Future of Public Health. Washington DC; National Academy Press; 1988.
Public Health Functions Steering Committee. Public Health in America. Washington, DC: PHS; 1995.
CDC. Ten Great Public Health Achievements - United States, MMWR. 1999;48(12);