1. SPNS IHIP Oral Health Webinar Series: Dental Case Management ………………. Presented by Dr. Howell Strauss and Nelson Diaz of AIDS Care Group and Dr. Carolyn Brown and Lucy Wright of the Native American Health Center January 9, 2014

2. Agenda ■ Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project ■ Sarah Cook-Raymond, Managing Director of Impact Marketing + Communications ■ Presentations ■ AIDS Care Group of Chester, PA ■ Dr. Howell Strauss, Executive Director & Dentist ■ Nelson Orlando Diaz, Dental Case Manager & Community Health Worker ■ Native American Health Center of San Francisco, CA ■ Dr. Carolyn Brown, Dental Director, Programs & Development ■ Lucy Wright, RDA, Dental Program Coordinator & Former Patient Navigator ■ Q & A

3. IHIP Resources on TARGET Center Website www.careacttarget.org/ihip

4. IHIP Oral Health Resources ■ Training Manual ■ Curriculum ■ Pocket Guide ■ Webinar Series ■ Healthy Mouth, Healthy Body (Held Dec. 13) ■ Dental Case Management ■ Clinical Aspects of Oral Health Care for PLWHA Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the live event: www.careacttarget.org/ihip

5. Other IHIP Resources ■ Buprenorphine Therapy ■ Training Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settings ■ Engaging Hard-to-Reach Populations ■ Training Manual, Curriculum, and Webinars on engaging hard-to- reach populations ■ Jail Linkages ■ Training Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings ■ UPCOMING: Hepatitis C Treatment Expansion ■ In Spring/Summer 2014, look for training materials on increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.

6. AIDS Care Group Outreach and Dental Case Management

7. Clinical services  Medicine  Dentistry  Medical case management  Nutrition  Psychiatry  Psychosocial services

9. Social and Medical Factors Affect Individual and Community Health There is poverty, joblessness, homelessness, and despair. Crime, substance abuse behaviors, and/or mental health conditions affect access to and retention in care. Dental care historically lacking in this targeted population.

10. Historical Review of Access to Dental Care  1980s: Regardless of ability to pay, dental care was inaccessible.  Early 1990s: One of two dental schools in Philadelphia accepted HIV positive patients.  Middle 1990s: Americans with Disabilities Act: All dental practices are offices of public accommodation.

11. History continues  New ways devised to deny dental care: “This office does not accept Medicaid dental insurance.”

12. Barriers to Care  Fear of the dentist  Inability to pay  Need to be asleep  No way to get there  Other family and health issues

13. Newly Constructed Barriers  To get care in the Ryan White setting, you must present your papers.  “Papers, please.”

14. Special Projects The AIDS Care Group was awarded a Special Projects of National Significance grant for “Oral Health Care – Outreach Project” A new clinic was established in Coatesville in October, 2006

30. Dental Case Management   Outreach stresses the need to go where people are receiving the most basic of their needs.   It can mean meeting people in hospitals, food distribution centers, religious meeting places, or social service agencies. It can also mean meeting people in prisons and jails, drug and alcohol treatment centers, or crack-houses.   The dental case manager is the glue that keeps the program together.

31.   Linked patients, papers, and providers.   Liaison between medical and social services providers, family members, and dental staff.   Transportation: New van logged 35,000 miles in first year of operation; exclusively for the dental outreach program.   Other enhancements: food, clothing, gas cards, chief kibbitzer.

32.  New dental clinic established.  New dentist hired.  Staff added from the community.  Outreach provided to multiple communities.  Start-up time: 4 months.  Full patient schedule within 6 months.  Over 600 patients treated.

33.  Program sustained to this day, using the same model of outreach and removing barriers to care.

35. 2014 HRSA/SPNS IHIP Dental Case Management Webinar Native American Health Center Carolyn Brown, DDSLucy Wright,RDA Dental Director Dental Program Coordinator Former Patient Navigator Carolynb@nativehealth.orgCarolynb@nativehealth.orgLucyw@nativehealth.org

36. Building the Case for NAHC’s Patient Navigator (Pre-2006)  Wide range of dental services offered at NAHC –Compact dental team focusing on clinical services  Referrals for HIV+ persons from 14+ agencies to NAHC dental  Sporadic success in managing dental treatment –Sometimes resulted in incomplete appointments, missed appointments –Confusion on the part of the patient, NAHC and referring agency –Dentist or over burdened receptionist often requesting + med info –Most treatment plan completions for patients with the least amount of access issues –35% no-show rate for dental appointments from HIV+ patients referred from partner agencies 1 1- Goddard G, Brown C, and Ahmad S: Oral Disease Prevalence among HIV-Positive Native American Indians in an Urban Clinic, Journal of Psychoactive Drugs, Vol 37 (3), Sept 2005. PMID: 16295015

37. Creating Dental Case Management  The chicken or the egg? Option 1: Dental staff and train for case management Option 2: Case manager and upgrade dental i.q.

38. Patient Navigator- GOALS  Increase Access –Identify barriers to care during interviews, and treatment; customize support or ancillary services  Intro the idea of a dental home –Patient will identify with NAHC, their dentist, and dental case manager as THEIR provider, fostering understanding and motivation towards treatment plan completion  Build Team Mentality –Build cohesiveness of the dental team –Bridge resources with medical case managers –Bridge resources for referrals –Partner w. the patient, and care givers to meet their needs and accomplish their dental goals –Identify other medical or community resources for the patient

39. Patient Navigator- A Day in the Life of… 9a -HIVQUAL audit prep 9 30 a- Pick up food from Food Bank 10a- Accompany patient to the oral surgeon 11a- Call 10 patients for appt reminder; Remind 1 patient to bring lab work 11 30 a-Coordinate with oral sx’s office on patient’s f/u instructions 12p- Answer patient’s email who is confused about appt time; review incoming faxes and lab work 2p- Intake 2 new patients; f/up with 1+ 3p- Meet with DDS to review tx plan progress 4p- Review treatment plans with DDS 4 30 a- Call patient from oral surgery appt; follow-up 5p- Meet with 1 patient after dental appointment

40. Findings from the SPNS projects Clinical:  Improvement in overall health status  More likely to complete Phase 1 treatment plans  More likely to be retained in dental care Patients:  Availability of DCM  Increase access  Knowledge  Empathy and offer comfort  Patients credited overall health improvement to DCM LeMay, Tobias, Umez-Eronini, Brown,McCluskey, Fox, Bednarsh and Cabral.Dental case manager encounters: the association with retention in dental care and treatment plan completion. Spec Care Dentist. 2013 Mar-Apr;33(2):70-7. LeMay, Cashman, McDonald, Graves. A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager. Prev Chronic Dis. 2012;9:E158.

41. NAHC HOPE/SPNS Study 2007- 2010 Results  DCM (n= 85) and non-DCM patients (n=205) very similar populations  DCM patients had significantly higher: –Phase 1 treatment plan completion –Low intensity preventative treatments –Higher number of dental appointments/yr –Higher likelihood of keeping appt. –Higher reported oral health quality of life Brown C, Ponnala S, Kim J. Oral Presentation: “Maximizing Clinical and Health Outcomes: HIV+ Dental Case Management”. International Association for Dental Research, Miami, FL. April 1-4, 2009.

42. NAHC’s Patient Navigator Success  No show rate for HIV+ dental patients at 5% from 35% over 4 years  118 patients who have been out of care recruited and retained  88+ specialty referral appointments kept and treatment received  Close partnership with 10 medical clinics specializing in HIV+ care  Added 2 nd Dental Case Manager; Ratio was 40- 50 patients : 1 DCM

43. The State and Future of HIV Research Goal #3: Optimizing treatment and care of the HIV-infected individual “I never really had good teeth, but my T cells have actually gone up to 600 since I’ve been here getting my teeth fixed. My health improved so much; I’m so grateful! I never realized that I needed help in getting here. I love Lucy, my DCM.” Mike M.

44. Strategies for Success NAHC SPNS Team Sridevi Ponnala, DDS, Clinical Director Carolyn Brown, DDS, Dental Director Eulalia Valerio, Director, Projects & Evaluation Lucy Wright, RDA, Dental Patient Navigator Gloryanna Valerio-Leonce, Data & Intake Manager

45. Next Oral Health Webinar Clinical Aspects of Oral Health Care for PLWHA January 22, 2014 at 3 PM EST More information available at: https://careacttarget.org/library/clinical-aspects-oral- health-care-plwha https://careacttarget.org/library/clinical-aspects-oral- health-care-plwha Presenters: Dr. David Reznik, HIVDent and Grady Health System of Atlanta, GA Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston Public Health Commission of Boston, MA

46. Q & A Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300www.impactmc.net Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications To be informed about Webinars and other upcoming IHIP resources, sign up for the IHIP listserv by emailing scook@impactmc.netscook@impactmc.net. IHIP Web site: www.careacttarget.org/ihip