1Dental Therapy in Minnesota: A Study of Quality and Efficiency Outcomes Sarah Wovcha, JD, MPH, Executive DirectorEmily Pietig, DDS, Dental Therapy Supervisor
2Children’s dental services CDS Mission Statement:Since 1919 Children's Dental Services is dedicated to improving the oral health of children from families with low incomes by providing accessible treatment and education to our diverse community.
3Dr. Emily Pietig Introduction Education: -University of Minnesota School of Dentistry-Desire to work in Public HealthHistory of practice at CDS:-Dentist driven-Portable-Focus on low-income schools and Head Starts
4Why was Dental Therapy considered? CDS background:-previously housed in public health department-as independent entity struggled for funding-swelling patient population-sought alternatives: foreign trained DDS, mid-level
5First Impressions:Dentists’ biggest source of information about the field=local dental associationMany questions arose about:-quality-ability to handle uncooperative patients-impact on patient care
6Hiring: the first DTs/ADTs In Minnesota Christy Jo Fogarty, a graduate of Metropolitan State University, was the first ADT hired and credentialed in Minnesota. Employed at CDS since December Became Minnesota’s first licensed ADT in January 2013.CDS’ most recent ADT hire is Jodi Becker who graduated from Metropolitan State University Program in June 2014CDS hired Elizabeth Branca, its third ADT from the Metropolitan State University Program, in June 2013.
7Integrating DTs into practice: Integration structure:-similar to dental school: start, prep and final checks-initially screened to ensure simple cases-team composed of 1 DDS, 2 DTs, 1 RDH-added column for each DT plus additional exam column
8Observations of DTs/ADTs -strong clinical skills-significant experience (in school I did 1 SSC, DTs do an average of 50 SSCs; in dental school I received no motivational interview training, DTs receive training on an average of 10 motivational interviews)-good behavior management-mature, experienced professionals-motivated
9Impact on the Dental Team Requires increased communication which has developed into cohesive team experienceThe DTs questions and desire to learn has spurred additional learning among DDSOpportunity to reflect on clinical decisions through teaching/supervisingFrees DDS to focus on specialized restorative care (DDS appreciate opportunity to hone higher skill level & relief from routine care)Overall increase in quality of careOverall reduction in cost of care
10Suggestions/Final Thoughts Ability to do prevention is useful for the highest efficiency of the clinical teamDentistry must embrace non-traditional clinical models to fulfill its duty to provide high quality care to all people regardless of income or insurance status
11Sarah Wovcha, JD, MPHChildren’s Dental Services was established in and received non-profit status in 1954Minnesota’s primary provider of portable dental care to low-income childrenFirst provider in the nation of on-site dental care in Head Start settingServes entire state
132013 DemographicsIn 2013 CDS treated 32,128 patients who were provided 69,317 procedures over the course of 42,549 visits.Somali/East African (25%), Latino (24%), African American(20%), Caucasian (17%), Hmong/Southeast Asian (8%), and American Indian (6%).59% female, 41% male80% receive Medical Assistance (MA), 19% are uninsured and enrolled in sliding scale programs (80% of whom receive free care), and less than 1% have private insurance.
14Focus on culturally targeted dental care Language fluency: CDS’ staff speak over 16 different languages and hail from 20 countriesRepresenting cultures served: Understanding the cultural norms, religious needs and diets of target communities staff create culturally targeted and translated curriculum for care in school-based settings
15Why Advanced Dental Therapists are a solution Community-basedMore continuously present than scarce dentistsEngage patientsNaturally integrate preventive care and education into patient visitGain expertise on limited scope of restorative proceduresFree dentists to practice at “top of license” and focus on complex cases
16Practice Settings for Minnesota ADTs Subd. 2.Limited practice settings:An advanced dental therapist licensed underthis chapter is limited to primarily practicing insettings that serve low-income, uninsured, andunderserved patients or in a dental healthprofessional shortage area.https://www.revisor.mn.gov/statutes/?id=150a.105
17Characteristics of ADTs All ADT services can be provided under General Supervision.General Supervision is defined in Minnesota Rule : “The supervision of tasks or procedures that do[es] not require the presence of the dentist in the office or on the premises at the time the tasks or procedures are being performed, but requires that the tasks be performed with the prior knowledge and consent of dentist”.ADTs will therefore directly increase access to care by providing care in rural or low- income area where access is a huge problem.While ADTs are not required to undergo chart review by Dentists, CDS ADTs do consult and review cases in a collaborative manner.Teledentisty and frequent communication enables these reviews for Dentists practicing in Minneapolis and St Paul and for ADTs practicing in Greater MN.CDS currently employs 1 Dental Therapist and 5 Advanced Dental Therapists
18Procedures performed by ADTs Oral Evaluation and AssessmentNon Surgical Extractions of Primary and Permanent teethRestorationsOHIX-RaysPreliminary chartingDressing changesAdministration of nitrous oxideSuture removalPlacement of temporary restorationsAtraumatic restorative therapyAdministration of local anestheticApplication of desensitizing medication or resinTissue conditioning and soft relineTooth re-implantation*all of these can be done under general supervision-which states that the dds does not have to be there in person, but that the ADT must be in a collaborative management agreement and be able to confer with that particular dds
19Procedures performed by ADTs, cont. PreventiveEndoMouthguardsMechanical PolishingApplication of topical preventive or prophylactic agents, including fluoride varnishes and sealantsPulp vitality testingPulpotomies on primary teethIndirect and direct pulp capping on primary and permanent teethFabrication of athletic mouth guardsFabrication of soft occlusal guards*all of these can be done under general supervision-which states that the dds does not have to be there in person, but that the ADT must be in a collaborative management agreement and be able to confer with that particular dds
20Collaborative Management Agreements Collaborative Management Agreement (CMA): a formal agreement detailing roles and responsibilities for dental therapists and advanced dental therapist and supervising dentistsStatute requires all advanced dental therapists to engage in a CMANo more than five DTs or ADTs can enter into a collaborative agreement with a single DDSCMAs must include:Practice settings and populations to be servedAny limitations of services provided by the DT or ADT and level of supervision requiredAge and procedure specific practice protocolsDental record recording and maintaining proceduresPlan to manage medical emergenciesQuality assurance planDispensing and administering medications protocolProvision of care to patients with special medical conditions or complex medical histories protocolSupervision criteria of dental assistantsReferral and reallocating clinical resources protocolCollaborating DDS accepts responsibility for unauthorized care provided by DT/ADTADT/DT must submit signed CMAs to the Board of Dentistry prior to providing care
21Fitting into the Dental Team According to the PEW Center on the States a team approach to dentistry has been found to be the most effective and provide the most access to dental care:“In solo private dental practices—where most dentists work—adding new types of providers and dental hygienists produced gains in productivity and increased earnings by a range of 17 to 54 percent. Dentists who operate a practice by themselves can increase their pre-tax profits by six or seven percent by accepting more Medicaid-enrolled children and hiring either a dental therapist or a hygienist-therapist”.
22Fitting into the dental team Traditional team: DDS, RDH and LDA.Today: DDS, ADT, Collaborative Practice RDH, RDH, LDA, Unlicensed DA.Integrating ADT:Scheduling own column of patientsProgram producing highly skilled and qualified cliniciansQuote of one CDS dentist about working with CDS ADT: “She completes fillings better than I do. I don’t know why I am checking her work.”
23Issues of Quality and Risk ADTs and DDS undergo the same licensure exams for procedures they both provide.Marsh Insurance provides professional liability coverage for ADTs currently licensed as dental hygienists and members of ADHA. The cost is approximately $93/year.Professional malpractice insurance from various providers range in cost from $564 to $1,209 for CDS’ dentists (average cost is $775/year)
24CDS’ data on Dental Therapy Care Since December of 2011, CDS’ DTs and ADTs combined have provided care to over 6,000 patients.There have been 3 requests to see a dentist instead of a dental therapist.There have been no complaints or claims of poor quality.Over 90% of survey respondents state that they are satisfied or very satisfied with the quality of care received by a DT or ADT.
25Results: Production NOTE: based on billing in community clinic setting with lower than average feesProduction Summary August 2011Provider CodeTotal Production ChargesTotal Hours WorkedTotal ProductionDR11 Endo Provider10,04024$418.33DR0155,165136.8$403.25DR204,17811.5$363.30DR1247,261148.85$317.51DR2436,518120.16$303.91DR3645,898161.53$284.15DR3837,646144.96$259.70DR4226,105116.7$223.69DR048784.65$188.85DR417,30140.09$182.12DR438,73951.45$169.85DR443,61624.2$149.42DR307,67851.83$148.14
26Results: Production 2012 Provider Code Total Production Charges Production Summary August 2012 (CDS began tracking DT productivity in March. ADT productivity has consistently risen since that time.)Provider CodeTotal Production ChargesTotal Hours WorkedTotal ProductionDR11 Endo Provider6,42016401.25DR0166,696130.39511.51DR042,1324.35490.08DR204,97412414.50ADT0166,508171388.94DR1243,978150.66291.90DR3643,562162.35268.32DR4322,94685.95266.97DR4443,219174.65247.46DR3827,094111244.09DR4220,75785.94241.53DR2423,861110.2216.52ADT029,39052180.58DR413,01723.55133.79
27Production Summary August 2013 Results: Production 2013Production Summary August 2013Provider CodeTotal Production ChargesTotal Hours WorkedTotal ProductionDR11 Endo Provider8,51616$532.25DR2019,34343.15$448.27DR4453,555138.05$387.58ADT0146,755123.5$378.58DR2453,507144.91$361.45DR3642,304140.05$302.06DR0141,008144.96$299.66DT014,27716.3$262.39DR433,3824.65$207.48DR1257,856171.87$203.46DR5310,67662.74$170.16DR044873.05$159.67
28Summary of Dental team production results with integration of dental therapist 2011: Average production of team is $280.72/hr2012: Average production of team is $298.09/hr ($ adjusting for fee increase); Average production of DT/ADT is $340.35/hr2013: Average production of team is $ per hour ($ adjusting for fee increase); Average production of DT/ADT is $365.04/hrDTs are vital to the financial viability of CDS; other clinics, such as private practice dentist Dr. John Powers, are seeing similar productivity and financial impact
29Results: Financial Impact DDS Cost $75/hrADT Cost $45/hrADT provides restorative care to 1,500 low-income children and pregnant women per yearTotal Cost Savings using ADT Pubic Health Model:$1,200/week$62,400/yearCost-Benefit Analysis based on 1 ADT providing services covered under the ADT statute for 40 hours/week in a public health dental clinic.
30Lessons Learned/Suggestions Graduated ADTs are in high demand for employmentAbility to do preventive care in portable settings is useful.Ability to practice under general supervision allows flexibility and frees clinic space for additional providers.Supervising dentists find that quality of care is excellent with both DTs and ADTs.Entire dental team is more efficient with integration of a DT or ADT.There have been no patient complaints related to any dental therapy work.Flexible and transferable model of care delivery.