1. National Primary Oral Health Care Conference December 9-13, 2007
CROC: Taking a Bite Out of Early Childhood Cavities on the Eastern Shore
National Primary Oral Health Care Conference
December 9-13, 2007
San Diego, CA
Scott Wolpin, DMD

2. Where is the Eastern Shore of Maryland??
The Eastern Shore of Maryland is composed of the state's nine counties east of the Chesapeake Bay. The Eastern Shore has always been a unique region, and has even attempted to split off from the state of Maryland. Proposals have been debated in the Maryland General Assembly in 1835, 1852 and recently in 1999 for the Eastern Shore becoming its own state. And even though seven of the nine counties have a majority of Democratic-registered voters, most elected officials are Republicans.

3. The main economic activities on the Eastern Shore are vegetable and grain truck farming, waterman work on the bay harvesting seafood, there is significant chicken farming - the Perdue Company began in Salisbury, Maryland, and services related to tourism. Ocean City is an seasonal resort destination for many on the east coast.

4. CROC Children's Regional Oral health Consortium
Transportation across the Chesapeake Bay was by ferries until 1952, when the first Chesapeake Bay Bridge was opened for traffic. The bridge spans over 4 miles of the Chesapeake Bay and is the longest continuous over-water steel structure. A second bridge was added in 1973 and a third is in the planning stages. This bridge is very intimidating to many of my patients who have been raised on the Eastern Shore but have never ventured over this bridge.
On the East side of this bridge, lies the Eastern Shore of Maryland, where dental disease and lack of access to dental care is one of the region’s most critical health care issues. Considerable oral health disparities remain in this area especially among the low-income and pediatric populations. Historically, local dentists have not participated in the Medicaid program because of the low reimbursement rates and the complexity of processing claims, creating additional access barriers to dental care for low-income patients .
There are no known alligators in the Chesapeake but we do now have a CROC – or Childrens Regional Oral Health Consortium - a service delivery network developed to address these oral health access issues affecting the lower and middle six counties of Eastern Maryland.

5. Collaboration: the Stakeholders
Eastern Shore Area Health Education Center
University of Maryland Dental School
Choptank Community Health System
Three Lower Counties Community Services
Shore Health System (DGH, EMH)
The stakeholders of the Children’s Regional Oral Health Consortium (CROC) include the Eastern Shore Area Health Education Center (AHEC); the University of Maryland (UMD) Dental School; two federally qualified community health centers, Choptank Community Health System, Inc. and Three Lower Counties, Inc.; and a local hospital group, Shore Health System, Inc.

6. How does a community raise a CROC?
In 2004, a 1 year HRSA Planning Grant was used to set the table
Eastern Shore Oral Health Action Network (ESOHAN) assembled
In 2005, a 3 year HRSA Rural Health Outreach Grant proposal is submitted/funded
In late , Wicomico County Health Department from the lower Eastern Shore pursued a 1 year HRSA Planning Grant to establish a network of those working in community-based care to improve oral health services for children and low income families living on the Eastern Shore of Maryland
Consequently the Eastern Shore Oral Health Action Network (ESOHAN) was assembled, many meetings were held, and substantial data accumulated including a direct survey of practicing dentists in the region.
The ESOHAN discovered substantial access limitations of the existing health care system including no dental home for Medicaid insured children in Dorchester County – the heart of the CROC project and Shore’s most urban-like county.
At the end of the planning grant year, in late 2005, the ESOHAN assembled to consider future options. With strong partnerships in place, substantial data accumulated, oral health needs clearly identified the decision was made to submit a proposal for a 3 year HRSA Rural Health Outreach Grant. And so a proposal was drafted to meet the goals and objectives set by Healthy People 2010, the HRSA goals for rural health programs, and the health needs of the community – the CROC grant. The community’s outcry of a recent, child’s death as a result of dental disease across the Bay, on the Western Shore, has further impassioned the network.

7. Community Responsiveness
The hope is for Medicaid-insured children to access primary and specialty dental services closer to home, to give every child on the Shore a healthy start…
The overarching goal of the CROC grant is: to increase availability of and access to comprehensive oral health care services in order to 1) prevent and control oral disease and injuries in children and adolescents; and 2) eliminate oral health disparities in the service area. So ESOHAN, funded by a HRSA planning grant, had set the stage for further expansion of existing oral health services in the region by being responsive to the community’s needs. The grant was approved in May 2006.

8. The Shore can be broken into three regions; the Upper, the Middle and the Lower Eastern Shore. Wicomico County in the Lower Eastern Shore submitted the HRSA planning grant.
All of the Middle Shore served by Choptank Community Health System and the majority of the Lower Shore served by Three Lower Counties Community Services are designated rural areas by the Office of Rural Health Policy. All six counties comprising the Middle and Lower Shore have been designated dental health professional shortage areas by the Health Services and Resources Administration.

9. Innovation: CROC’s Charge
Develop a dental home for Medicaid and uninsured children of Dorchester County
Develop a regional hospital-based pediatric dental program for children requiring GA
Develop clinical and community-based education training opportunities for dental hygiene students
The consortium’s charge is to improve the availability of and access to preventive, restorative, and rehabilitative oral health care for low-income children on the Eastern Shore and hopes to do so using a three legged approach:
Improve access by the development of a comprehensive dental center in Dorchester County;
Expand specialty care with the development of a regional hospital-based pediatric dental program for children requiring general anesthesia;
and Increase the workforce by the development of clinical and community-based education training opportunities for dental hygiene students.
I hope to demonstrate that these three strategies are interrelated as I continue to share our story.

10. Dorchester County – the heart of a CROC
Dorchester County, the heart of the grant, is a geographically large, relatively poor rural county located in the middle of Maryland's Eastern Shore. The county consists of 593 square miles of land with 1,700 miles of shoreline. More than 35 percent of the county's residents reside in Cambridge, the county seat.
There are significant geographic features in Dorchester County that pose barriers to accessing medical and dental care. These include large tracts of wetland and marsh, around which roads are routed; isolated islands and peninsulas, some of which are separated from the mainland during high tide; and limited public transportation outside of Cambridge

11. Dorchester County
Top 4 of Maryland’s 24 counties with worst child health indicators
Half of all children in the area are eligible for Medical Assistance
No dental home for Medicaid-insured or uninsured children
The county demonstrates many characteristics of underserved, rural areas. Compared with the rest of the State, Dorchester has higher poverty levels, a higher percent of uninsured residents; lower median income; and a higher unemployment rate. Half of the children in the area under fifteen years of age are eligible for Medicaid. Out of the 24 counties in the State, Dorchester County is ranked among the top four counties with the worst child health indicators. The real surprising concern ESOHAN discovered when performing a needs assessment is that prior to CROC there was no dental home for Medicaid or uninsured children

12. Target Population
All low income children in Dorchester County – uninsured or enrolled in MA
Immigrant and migrant worker’s children
And there are approximately 4000 children under 21 years of age residing in the county who are eligible for Medicaid. Thirty-five percent of children in Dorchester County are African-American and three percent are Hispanic. Many in this Hispanic population have immigrated from Mexico and Guatemala for employment in poultry business.
In addition to the immigrant population, migrant farmworkers arrive each Spring in the area. The majority of the migrant farmworkers in this area travel with crews from Texas or Florida to harvest truck crops, ninety percent of them are native Spanish-speakers and fifteen percent are children.

13. Oral Health
In a survey conducted every five years by the University of Maryland dental school and the State Office of Oral Health, children living on the Eastern Shore were found to exhibit more dental disease than any other area of the state. The Maryland survey results indicate that low-income children, those eligible for free/reduced lunch, have 52 percent more untreated dental caries. The Maryland Survey also showed that school-age children on the Eastern Shore were the least likely in the state to have seen a dentist within the past year.
On the Eastern Shore, only fourteen percent of school children were found to have sealants on at least one tooth. We know how effective sealants are in reducing the incidence of pit and fissure decay on permanent teeth however they are being grossly underutilized, particularly among low-income children.

14. Water Fluoridation*
Poor oral health is complicated in this rural area by the inconsistent availability of fluoridated water supplies. The systemic and topical beneficial effect of fluoride is well documented. We know that fluoridated community water systems are the most cost effective measure to reduce the incidence and prevalence of dental caries. Children living in non-fluoridated communities have nearly fifty percent more decayed teeth than children living with fluoridated water. In Maryland, 93 percent of the State’s residents have public water systems and receive fluoridated water. But many of the children on the Eastern Shore live in homes that do not have communal fluoridated water, only anywhere from 14 to 57 percent of the population has access to fluoridated water. Fortunately, Dorchester County, because it is our most urban-like, had the highest number with fluoridated communal water.
* Determined by the difference between Public Water Systems with Fluoride > 0.8ppm and total population, for each county

15. Medicaid-insured Children in Maryland
The percentage of Maryland school children with decay is 60%. The national average is 50%. 75% of the decay is found in 25% of the children (MA)
Children who are eligible for Medicaid, Free or reduced lunch programs have over 30% more cavities than the state average
All children who receive Medical Assistance have 70% of their cavities untreated, whereas children who pay for dental services through insurance or out-of-pocket average 50% untreated disease
Only one-third of medical Assistance eligible children see a dentist every 6 months. The state average is 48%.
These are just some more statistics again showing that Medicaid-insured children in Maryland have more disease and are less likely to visit a dentist for care. This story, of course, is the same for many our States.

16. Mouth of a two year old child
Oral Health
Clinically, this is what the problem looks like for many of our infants and toddlers. This is a two year old with severe Early Childhood Caries “whose mom described that her child’s teeth are melting away.” We know that the cost of this easily preventable disease is thousands of dollars when it requires treatment in the hospital setting. We know that this is a child who will experience pain, difficulty eating, speaking and poor self esteem as they grow. And we know what can happen if the disease is allowed to run it’s course from the story of Deamonte Driver, the 12 year old Maryland boy who died from a brain abscess from infected teeth across the Bay in Prince George’s County, Maryland. This is an unacceptable cost.
Mouth of a two year old child

17. This is an osprey, or Seahawk
This is an osprey, or Seahawk. They are large fish eating birds that live on the Shore. Some have been even been know to eat small alligators – hopefully not CROCs!

18. Maryland’s Medicaid Reform Program: HealthChoice
Initially there were 7 dental Managed Care Organizations (MCO) but he State is now hoping to move to a single vendor
On the Eastern Shore, less than ten percent of the 160 practicing dentists accept Medicaid-insured patients
In Dorchester County, there are no dentists accepting Medicaid-insured patients
In the late 90’s Maryland’s Medicaid program was renewed. The transformed program, called HealthChoice, provides health care for approximately 75 percent of Medicaid eligible patients in the State through Managed Care Organizations (MCOs). The MCOs are private insurers that contract with a network of providers to provide covered services to their enrollees. HealthChoice MCOs are required to offer comprehensive oral health services to children up to 21 years of age and pregnant women. Dental services for adult patients were initially offered by some MCOs, these services were then limited to emergency care and then discontinued by all MCOs in 2004, however many are now adding some basic dental benefits back. The MCOs are required to develop an adequate network of oral health providers to assure that the provider to enrollee ratio is no higher than 1:2000. However, this ratio is much higher on the Eastern Shore. On the Eastern Shore, less than ten percent of the 160 practicing dentists accept Medicaid patients. And in Dorchester County, there were no dentists accepting Medicaid patients before CROC.

19. Workforce Disparities
There are three training programs for dental hygienists in Maryland, however, none are located on the Eastern Shore
Not only is there a shortage of hygienists on the Eastern Shore, less than ten percent of the dental hygienists work with the target population
As with other rural areas, there are also workforce disparities on the Eastern Shore. For example, there are three training programs for dental hygienists in Maryland, however, none are located on the Eastern Shore. We know that dental hygienists are the midlevel provider for dentistry, perhaps the best providers for delivering anticipatory guidance and preventative care.

20. Integration: Public Health Initiatives
Pediatric Dental Fellows
Satellite Dental Hygiene Training Program
Statewide, several public health initiatives have been developed, over the past years, to increase access to oral health care for HealthChoice recipients.
In 1999, the UM Dental School, the State Office of Oral Health, local health departments and FQHC community health centers developed a partnership to place trained pediatric dentists into community clinics. This is a creative model where community partnerships can resolve a regional problem. Even though we have some safety net dental providers on the Shore, practicing in our community-based dental programs, many of them are not comfortable or do not have the competencies to care for the youngest with complex, clinical needs. A pediatric dental fellow started providing services at our health center in May Each fellow has a two year commitment and these specialty dental providers are able to locally treat children who previously had to be referred to the dental school or Baltimore hospital programs. So we now have these specialty care services closer to home.
In addition, progress has been made recently in tackling the workforce issue. A satellite dental hygienist training program has been established by the University of Maryland Dental School. Here students from the Eastern Shore can attend didactic classes via distant learning (video teleconferencing) at our local community colleges and their clinical training in local dentist offices, and community-based dental programs. The third leg of the CROC grant is to help identify and provide these learning opportunities close to their home.

21. These are my friend’s gun dogs that are used for waterfowl hunting
These are my friend’s gun dogs that are used for waterfowl hunting. They love the water and so they are very happy dogs on the Shore.

22. “Titanic Approach”
Until a complete oral health team network can be established and/or CCHS expands services, the following guidelines were developed to provide oral health services:
Patients must reside within Caroline, Dorchester or Talbot Counties
Services will be targeted to children who are uninsured or enrolled in HealthChoice/MA
Services for adult patients will be targeted to those with emergencies or are referred by medical providers for chronic illness (i.e. HIV, diabetes, etc.) or pregnancy
Still after these initiatives, because local dentists are still not participating in the Medicaid program, there are tremendous access barriers to dental care for low-income patients. While there are the two Federally Qualified Health Centers (FQHC) on the Eastern Shore that serve as safety net care providers for these patients, the ability to schedule non-urgent restorative care and preventive care still remains at maximum capacity for both health centers. Recognizing that in this current health care environment, where few private dental offices see Medicaid-insured patients, and that our health center cannot provide services for all in need with our existing capacity and resources, our health center has implemented a public health approach. I am sure that this is not a unique concept to anyone in this room and it is what Drs. McFarland and Rosenstein refer to as the Titanic Approach.
That is, care is targeted to Medicaid-insured children within the health center’s defined service area, adult patients may present for open access/same day acute care but must be referred by their primary care provider if they desire routine restorative care. Patients with diabetes or who are pregnant are given priority.

23. Lack of Specialty Care
No services were available on the Eastern Shore for children who require oral rehabilitation under general anesthesia prior to CCHS’s hospital-based pediatric dental program
To accommodate the surgical and restorative needs of young children locally, the existing hospital-based dental services will need to be increased to at least one day per week.
Before CROC, and before our first pediatric fellows came to our center, children who required specialty care because of extensive dental disease had no where to go – there was no local hospital-based dental program offering general anesthesia. Children requiring this care, pre-cooperative children and those with special health care needs, had to travel to the UM Dental School in Baltimore for rehabilitative care. This is up to a three-hour commute, each way, for some of the families in our service area so as you can imagine that many did not or were unable to follow up with our referrals.
To meet the needs of children in our service area that have extensive dental disease, CCHS, in collaboration with the UM Dental School and our local hospital, is piloting a hospital-based dental program. The pediatric dental fellow, who is working in our health center now provides hospital-based dental services two days per month - scheduling two to three cases per day. So we are bringing about four children to the hospital each month. Still, in the past year, over 80 children from the six mid and lower counties on the Eastern Shore were seen at the UM Dental School in Baltimore for pediatric dentistry and our hospital-based care is backlogged five months. In order to accommodate these children locally, the hospital-based dental program needs to expand – this is hope of the second leg of the CROC grant where more OR time will be added permitting this pilot program to grow as a regional referral solution.

24. Building a Regional Referral System
This is our designated OR suite at Dorchester General Hospital in Cambridge. The equipment was purchased with a mini grant from Care First. It is our hope that the expansion of this program will allow patients from other mid- and lower-Shore counties on the Shore to also be treated locally and CROC has already developed procedures and a tool box to assure efficient referrals to the pediatric dental fellow from the other community-based dental programs and physician’s offices in the six county area we just need more OR time!

25. CROC/DGH Provider Staff

26. Why are we still seeing so much disease?
“Decay will happen anyway”
“Baby teeth are not important”
“The bottle keeps my baby quiet”
Even with these creative initiatives, and our public health approach to prioritizing care we are seeing many new young patients with extensive untreated dental disease each week. Besides the access issues, what parents know or do not know about oral health care, and the stressors they face from poverty, can influence their decisions on seeking oral health care, particularly preventive care, for their children. If parents are unaware of the need for routine oral health care or lack the experience in accessing care, the availability of care is relatively unimportant. Most of the children we have brought to the OR with extensive needs have caregivers who have neglected their own dental health and/or have visited our health center for acute dental services. They don’t see their dental problems as an infectious disease. A very simple message can intercept the crisis we are facing.
These are the kind of things I hear in our office each day…
READ SLIDE
There are cultural aspects contributing to the dental disease we are seeing. I often find improper infant feeding habits in migrant families who live in multi-household dwellings. Because the caregiver is concerned about the rest of others in the home, who must go to work the next day, the child is put to bed with a bottle.
There is incredible opportunity here for dental hygienists to share anticipatory guidance and primary prevention. But not only are we facing a workforce shortage, most of the dental hygienists who live on the Shore do not work with these high risk populations.

27. This is the Blue Crab before it is steamed
This is the Blue Crab before it is steamed. Crabs are a very popular food in the Chesapeake area. Our bay, much like the dental community, is not able to meet the local demand. During the summer months many local restaurants ship crabs in from Louisiana, North Carolina and Texas.

28. Measurable Outcomes
By 2008, at least 50 percent of low-income children in Dorchester County will have received preventive dental service during the past year.
Baseline: % in 2003 Healthy People 2010 Goal: 57%
By 2010, reduce the proportion of untreated dental decay in 6 to 8 year old children on the Eastern Shore to no more than 40 percent.
Baseline: 72 % in Healthy People 2010 Goal: 21%
Like picking crabs, the consortium worked hard to select realistic and measurable metrics to evaluate the project’s outcomes. READ SLIDE

29. So how are we doing??
A dental home has been built and 663 children have visited for 1143 visits (91%MA)
The hospital-based dental program has now added a second full day in the OR each month and over 40 children have received dental surgery at DGH
A dental hygienist/oral health educator has provided ECC prevention in-services to medical providers in three of our health center’s primary care offices, established many community linkages and assembled a referral tool box
Measuring outcomes anecdotally, because we have not yet formally evaluated the project, so far we have:
Built a dental home - our health center renovated an older professional building using its own reserve funding to use as an interim dental office space and this office, opened in late 2006 has provided over 1200 visits already - 91% of these by Medicaid-insured children
We have brought over 40 children to the operating room at DGH
And we have hired a dental hygienist/oral health educator who is strengthening linkages between community organizations, identifying training opportunities for dental hygiene students and providing training programs for non-dental clinicians to develop oral health services risk assessment, anticipatory guidance skills.

30. Replication
Stakeholders need to be identified (some are not traditional)
Meetings must be well attended – have food!
Strong partnerships must be cultivated then nurtured
Substantial data must be collected
Determine what health needs are a priority to the community
HRSA does not have a plethora of evaluation data, so we think CROC data will be welcome
A critical element for any network’s success is the continued commitment and collaboration of all consortium members. The CROC model is relevant and worthy of replicating and or adapting in other community-based dental programs serving underserved communities because the needs of our community, the inadequate, available resources to meet these needs and community partners are not unique.
The critical components are that all stakeholders must be identified (realize that some are not traditional – faith based?), meetings must be held that are well attended, strong partnerships cultivated then nurtured, substantial data needs to be obtained, and most importantly the health needs that are determined to be deficient considered highly important by the community itself. The process must be a collaborative not competitive one. In our project two FQHC dental programs are working jointly for a healthier community.

31. Sustainability
CCHS’s application to the Maryland Community Health Resources Commission was awarded
These monies will be used to expand our Cambridge dental office from three to seven treatment rooms and recruit a case worker to optimize OR utilization
Of course, the continuance of any project depends on it’s outcomes and success in future grant initiatives. This summer a RFP was released by the Maryland Community Health Resources Commission, and late this fall our health center building on our success in CROC was awarded this grant. Monies from this opportunity will be used to reinforce CROC - expanding the Cambridge dental office from three to seven treatment rooms and to recruit a case worker to improve utilization of the hospital-based dental services – making sure the children are reaching the operating room.

32. These, of course, are the crabs after steaming - they are definitely not a fast food. Instead they are a relaxing event spent with good company. Much like my experience with CROC, the consortium has brought together many friends who before were unaware of each other’s work . It has truly been a rewarding project in that it is improving our community’s health by increasing access to care, building linkages and growing a workforce to meet the health care needs of the region.

33. Scott Wolpin, DMD
Chief Dental Officer
Choptank Community Health System
Federalsburg, Maryland