Public Health Reports Meet the Author! Live Webcast Tuesday, May 22, 2012 | 1:00-2:15 PM (EST) You will be given a phone number and access code when you log into the webinar. Innovations in Oral Health Care for People Living with HIV/AIDS Speakers: Sara S. Bachman, Ph.D., Jane Fox, MPH, David Reznik, DDS, Carol Tobias, MMHS Guest Editors of the May/June 2012 PHR Special Supplement on Innovations in Oral Health Care for People Living with HIV/AIDS Moderator: CDR Mahyar Mofidi, Ph.D., DMD

Public Health Reports Special Supplement Innovations in Oral Health Care for People Living with HIV/AIDS

Webinar Learning Objectives Present findings from the Special Projects of National Significance (SPNS) Innovations in Oral Health Care Initiative. Describe ways to improve access to oral health care and associated outcomes for people living with HIV. Discuss ways innovative strategies can be applied to other vulnerable populations. Fills research gaps related to oral health care for people living with HIV/AIDS.

Special supplement to Public Health Reports presenting findings from the Special Projects of National Significance Innovations in Oral Health Care Initiative. The Oral Health Initiative encompassed 15 sites from around the country, about half in urban and half in rural communities. Results show innovative program models can engage and retain people who are living with HIV/AIDS into oral health-care. Articles in this special issue represent the most comprehensive additions to the body of knowledge about oral health care for people living with HIV/AIDS in a decade. Innovations in Oral Health Care for People Living with HIV/AIDS

The Initiative and Evaluation at a Glance The purpose of the Oral Health Care Initiative was to develop and implement innovative models of oral health care. The multi-site evaluation was conducted by the Health and Disability Working Group at the Boston University School of Public Health. Goals of the Evaluation Center included: – Help sites improve access and adherence to high quality oral health care for underserved populations. – Implement a mixed methods multi-site evaluation of the demonstration projects. – Assist grantees in implementing both the multi-site evaluation and their local evaluations. – Disseminate findings to a broad range of audiences including oral health care providers, medical care providers, consumers and policy makers.

Evaluation Questions Do the demonstration programs increase access to oral health care for the target population? What are the main similarities and differences in strategies and program models to increase access to oral health care across programs? Are the oral health services performed in accordance with professional practice guidelines? Do clients experience improvements in health outcomes over time? Are clients’ oral health care needs met? Do clients experience improvements in oral health related quality of life after enrollment in oral health care? What strategies are most effective in furthering successful program implementation: barriers, facilitators, key lessons learned? What strategies to address the structural, policy and financing issues can be replicated in other settings?

In this Webinar we will…. Provide a brief overview of key results of the multi-site evaluation Highlight innovative practices Describe lessons learned about sustainability and financing Identify applications to other vulnerable populations

Study Sample Demographics (N=2469) 75% male 40.3% black, 21.4% Latino 32.8 % high school education, 42.0% beyond high school 30.7% working 54.4% monthly income < $850 Mean age: 43.6 (18 – 81), Years positive: 9.54

Sample Baseline Characteristics Prior Dental Care Usual place for dental care: 37.6% none; 30.4% private dentist 48.5% reported needing dental care since testing HIV+ but were unable to access it Of those who could not access dental care, 64.4% stated cost/affordability as the reason Prior HIV Care 97.3% reported a regular place for HIV care and 95.5% had seen their HIV provider in the past 6 months 84.6% had an HIV case manager and 77.4% were taking ARTs 57.35% had a CD4 count over 350 and 44.2% had an undectable viral load

Increasing Access to Oral Health Care By the end of the study: Patients made over 15,000 clinic visits They received over 37,000 services 917 (42%) completed a Phase 1 treatment plan In the first 12 months of oral health care# provided Patients who received any service n % Clinic Visits11, % Phase 1 Treatment Plans Completed* % Comprehensive Exams % *Phase 1 Treatment Plan = Prevent and treat active disease

Program Models and Interventions Program models – AIDS service organizations – Hospital–based programs – Community Health Centers Interventions – Expansion of clinic space and/or services – Dental case management – Mobile dental units

Patient Perspectives on Innovation Impact Reasons for retention in oral health care – Staff and environment – HIV knowledgeable dentist – Dental case manager – Maintaining oral and overall health Impact of participation in oral health – Improved awareness about HIV health and oral health – Better oral health hygiene practices – Improved self-esteem and appearance

Innovative Practices The Rural Alliance Partnerships – HIV Alliance – Community Health Centers of Lane County – Lane Community College Service Delivery – Sites – Transportation – Staffing Dental hygiene students, dental assisting students, hygiene faculty, dentists, denturist, and a dental case manager.

Lessons learned about sustainability/financing Medicaid Adult Benefits Medicaid is a major source of health-care coverage, including oral health care, for PLWHA. Comprehensive adult dental coverage under Medicaid is only available in approximately 20% of states. More than half of the states offer emergency or highly restricted dental services only. Medicaid programs that offer some oral health benefits may not provide adequate coverage to eliminate oral disease.

Lessons learned about sustainability/financing Medicaid Adult Benefits Medicaid coverage for adult dental services has often been the victim of budgetary cuts during periods of fiscal retrenchment. A fiscal year 2010 survey of Medicaid programs reported a reduction in Medicaid adult dental benefits in 20 states, more than in any year in the past decade; 14 states planned to reduce benefits in FY 2012.

Limits of dental coverage for people living with HIV Medicaid Adult Benefits Most people with HIV who qualify for Medicaid do so by meeting the program’s income and disability standards. However, many PLWHA may not gain Medicaid coverage until their illness progresses to the point that they are determined to be eligible as a result of disability. Presently, 68% of PLWHA have incomes below 100% of the federal poverty level, yet only 34% qualify for Medicaid. Implementation of the Medicaid expansion contained in the Patient Protection and Affordable Care Act (ACA) would cover adults within 133% of the Federal Poverty Limit and would greatly benefit PLWHA. However, adult dental care is presently not included in the Medicaid expansion.

Lessons learned about sustainability/financing Ryan White HIV/AIDS Programs The Ryan White HIV/AIDS program, administered by the Health Resources and Services Administration, is the third largest public financing program for HIV/AIDS care after Medicaid and Medicare. Of note: Medicare does not offer a dental benefit but does reimburse for oral pathology services including biopsies and destruction/removal of lesions (e.g. oral condylomas). Grants from the Ryan White program provide funds that function as a “payer of last resort” for more than 500,000 uninsured or underinsured people each year. The majority of these recipients live below the federal poverty level and are ethnic and racial minorities.

Lessons learned about sustainability/financing Ryan White HIV/AIDS Programs The Ryan White program funds HIV-related health care and services through multiple grant opportunities called Parts. – Part A funds are awarded to eligible metropolitan areas that are disproportionately affected by HIV/AIDS – Part B funds are awarded to States – Part C and Part D funds target primary care providers in the community such as hospitals or community health centers. – Part F funds healthcare educational programs including the Dental Reimbursement Program, the Community- Based Dental Partnership Program, AIDS Education and Training Center and the Special Projects of National Significance program.

Lessons learned about sustainability/financing Ryan White HIV/AIDS Programs 75% of funding in Parts A, B and C must be spent on Core Services: – Primary Care – Medications – Oral Health Care – Mental Health Care – Substance Abuse Services – Medical case management/treatment adherence counseling Other services such as food, transportation, peer counseling, translation, etc. are considered support services

Program Sustainability Sustainability depends on several factors: – Medicaid dental coverage in the state – Leveraging multiple Ryan White Program funding sources to sustain the delivery of care. – Applying for foundation grants and other sources of funding outside of the Ryan White Program. – Leadership AIDS Service organization Dental providers

Sustainability: An Example HIV Alliance in Oregon – The SPNS Oral Health Initiative helped the program establish a dental clinic and hire a project coordinator. – The Ryan White Dental Reimbursement Program (Part F) created an ongoing source of revenue for oral health services. – Part B funding will fund the dental case manager, cover denture costs, and pay for transportation. – Foundation grants to cover additional costs.

Sustainability: An Example Tenderloin Health Care – The SPNS Oral Health Initiative was instrumental in establishing dental operatories in the same facility where clients received their HIV care. – The Dental Director of the San Francisco Department of Health, Dr. Avi Nath, successfully applied for Part A funds to sustain the program once SPNS funding ended. – Working with the University of California at San Francisco (UCSF) Dental School’s General Practice Residency Program (to manage some surgeries, endodontics and dentures) allowed UCSF the ability to apply for Part F Dental Reimbursement funds to help defray the costs.

Application to other vulnerable populations People with HIV, seniors, adults with disabilities are living longer: – More people, more teeth and more complex oral health care needs Self-perception of dental health is poor 1 50% of seniors say their teeth are poor or very poor Poor oral health is associated with weight loss, failure to thrive, pneumonia Oral health remains a much greater need – more so than general health care The national survey of children with special health care needs chartbook Rockville, Maryland: DHHS 2007.

Similar Barriers to Care Overall access barriers 30-50% of adults with disabilities have significant barriers to dental care 3 Only 43% of seniors visit the dentist in a year 1 Financial barriers 70% of seniors lack dental insurance 1 Adults with disabilities are twice as likely to forgo dental care for cost reasons 4 Other barriers Transportation Finding a dentist who will treat them 3 Drainoni M, Lee-Hood E, Tobias C, Bachman SS, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care access. Journal of Disability Policy Studies Fall 2006 Fall 2006;17(2): Rapalo DM, Davis JL, Burtner P, Bouldin ED. Cost as a barrier to dental care among people with disabilities: A report from the florida behavioral risk factor surveillance system. Spec Care Dentist 2010 Jul-Aug;30(4):133-9.

Care Facilitators Dental provider education Outreach and transportation to services Care coordination, systems navigation, appt. follow up Service integration with medical care and social services Patient education

Outcomes beneficial for other vulnerable populations Eliminate pain and infection Improve overall oral health Engage- ment in preventive care Encourage better care of overall health Improving self-esteem Interpro- fessional team building

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