1. THE PEW REPORTS AND ADVANCED DEGREES DEBORAH A. COOK, RDH, MAED, BERGEN COMMUNITY COLLEGE

2. WHAT ARE THE THREE PROPOSED PROVIDER TYPES? The PEW center on the states three provider types: Dental Therapists Primary care providers of preventive and restorative care for children Introduced in 1921 in New Zealand and common in 53 countries The two year program resembles the last two years of dental school In the U.S., utilized in Alaska’s tribal regions Practice in satellite clinics under supervision of dentist in hub clinic

3. WHAT ARE THE THREE PROPOSED PROVIDER TYPES? The PEW center on the states three provider types: Community Dental Health Coordinators Proposed community health workers Would complete 12 month training and 6 month internship (required for dental assistants, EFDAs, RDHs, and CHWs) Work under supervision of dentists to triage patients and help them navigate health care system Proposed by American Dental Association As of March 2012, not accredited by CODA but hearings are scheduled at the joint ADA ADAA Annual Session Oct 31 to Nov 3

4. WHAT ARE THE THREE PROPOSED PROVIDER TYPES? The PEW center on the states three provider types:: Advanced Dental Hygiene Practitioners Proposed as case managers and primary care providers Would provide preventive and basic restorative care Would refer pts to dentists for more complex services The ADHA has developed a master’s degree ADHP program

5. WHAT ARE THE REASONS FOR PROPOSALS FOR NEW TYPES OF PROVIDERS? High rates of untreated dental problems in low income families, children, and minorities Survey of families in 2003-04 showed that 18% of Latino children and 16% of multiracial children had never seen a dentist 80% of caries occurs in 25% of children, many from low income families Shortages of private dentists who participate in Medicaid and CHIP Only one in three children under Medicaid received dental care in 2006 States are required to provide Medicaid dental coverage for children but NOT for adults (only 16 states provide comprehensive dental coverage and another 16 provide emergency care only to adults)

6. WHAT ARE THE REASONS FOR PROPOSALS FOR NEW TYPES OF PROVIDERS? Community health centers and similar safety nets only reach 10% of those who need care People without HEALTH insurance have bad teeth because going to the dentist seems like a luxury when you are paying for everything out of pocket When the economy is bad, optional benefits such as dental insurance are the first to be cut by employers Medicare does not include dental, so those over 65 must pay out of pocket or forego dental care Recognition of new providers ability to provide high quality care The current dental workforce does not meet the needs of special populations, such as young children, the elderly, and those with disabilities 93% of dentists are in private practice

7. HOW DOES THE DEMAND FOR CARE EFFECT THE PROVIDER SUPPLY? Access to care in Massachusetts In 2006, dental benefits through Medicaid were restored to 540,000 low income adults (eligibility expansion made this available to 140,000 more) Waiting lists at health centers increased to 3 months or more Only 17% of the state’s dentists accepted Medicaid so the wait list continued to grow Providing access to care needs to be coupled with increased availability of providers

8. WHAT OTHER DEMANDS WILL EFFECT SUPPLY? Baby boomers are reaching retirement age with more of their teeth, as opposed to the geriatric population 50 years ago By the year 2014, the number of dentists reaching retirement age will out pace the number of dentists graduating and entering the workforce Enrollment has dropped, from 6301 in 1978 to 4612 in 2004 Almost 40% of dental graduates in 2003 were female, and female dentists were twice as likely to work part time & to do so for more years There is an uneven distribution of dentists: too few in rural areas and inner cities, and too few who care for children, the elderly, the disabled, and low income families The ADA report in 2005 did say that “public programs for dental services must have the necessary resources to translate unmet need into effective demand”

9. WHAT TYPES OF WORKFORCE SOLUTIONS HAVE BEEN PROPOSED? Simply expanding public insurance coverage will NOT improve access to care; increasing the supply of providers must also be considered  Revamp dental school curricula to include community based settings/rotations  Offering repayment of loans to aid rural recruitment and retention  Increasing diversity in dental schools  Using physicians and nurses to provide oral health services to children

10. ARE THERE ANY ALTERNATE WORKFORCE SOLUTIONS? Research to Develop a New Provider type  Needs assessment and baseline data  Who does not have access to care? What is the characteristics of the population at risk? Where does this population live?  Inventory of current infrastructure  Dental workforce inventory:  Who is currently providing care? What are the providers characteristics? Where are they practicing? Where are the shortages?  Educational inventory:  Who are the eligible candidates? (recruitment and selection of students), What is the capacity of the institutions? What are the quality assurance controls? (accreditation, licensure), How will the graduates be recruited for their jobs? How will efficiency of the process be assessed? (attrition rates)

11. ARE THERE ANY ALTERNATE WORKFORCE SOLUTIONS? Research to Develop a New Provider type  Delivery system analysis  Can the current delivery system accommodate a new workforce model? Where will the new providers be deployed? (school based clinics, nursing homes, community based centers) Will they be licensed to practice anywhere? (or only in shortage areas) How will the new providers be reimbursed? Will they require supervision from dentists? Do they need to have a network for referral?  Financial Resources Survey  Who is covered by Medicaid and CHIP? What kinds of dental services are covered? Would new providers be able to be reimbursed by these plans?  Political landscape assessment  Who is likely to support or oppose the plan? What steps need to be taken to get a new provider approved? (new legislation)

12. WHAT IS A DENTAL HEALTH AID THERAPIST? Introduced in 2003 by the Alaska Native Tribal Health Consortium Alaskan native children 2-5 years old have five times the amount of tooth decay compared to other children in the U. S. Students are recruited from the area in which they will work, so they will be more likely to remain in that area and will be able to provide culturally competent care Upon completion of their two year program, they must spend 3 months or 400 hours working under the direct supervision of a dentist As of 2008, ten DHATs are providing care to thousands of residents in 20 villages University of Washington did an evaluation and found that high quality care was being provided and recommended expansion of the program DHATs scope of practice includes: dental screenings and assessments, taking x-rays and making diagnosis, applying sealants, fluoride, simple extractions and restorations. Complex cases are referred to the dentist.

13. WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR? Developed by the ADA in 2006 in response to the dental therapists in Alaska CDHCs would function as facilitators in communities, helping pts navigate the system, finding dentists who accept Medicaid, and providing education Would work under direct supervision of the dentist when providing direct pt care Certification, not licensure, would be required but this does not carry with it legal oversight, continuing education requirements, nor disciplinary power Scope of practice includes: assisting, applying sealants and fluorides, superficial scaling and polishing, and temporary restorations (hand instruments only) Two pilot projects were begun in California and Oklahoma where students would work with the Indian Health Service Program was designed by ADA and currently, is NOT accredited

14. WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR? 12 month online didactic program through Rio Salada College (Arizona) 6 month internship at the American Indian site and the urban site The pilot training program sites are: The rural site—University of Oklahoma. The hands-on clinical training will occur in Indian Health Service facilities, Tribal Clinics and Federally Qualified Health Centers. The American Indian site—A.T. Still University Arizona School of Dentistry and Oral Health (ASDOH) in Mesa, Arizona, The urban site—Temple University (Pennsylvania). The training for urban-based CDHCs will occur in Federal Qualified Health Centers

15. WHAT IS A COMMUNITY DENTAL HEALTH COORDINATOR? The PA Dept of Health classified North Philadelphia as an area suffering a shortage of dental health providers The ADA awarded a $1.14 million grant to the Maurice H. Kornberg School of Dentistry, Temple University in 2009 the school signed an agreement to become the urban site for the CDHC pilot program which would train 12 individuals from the community for this role Services to be provided included: screenings, fluoride treatments, sealants, and temporary restorations under remote supervision by dentists They will also help bridge the gap between local cultures and health care systems by helping patients gaining access to and becoming eligible for charitable dental programs The five year plan involves upgrading the school facilities and changing their approach to pt care to include more black and Latino populations

16. WHAT IS AN ADVANCED DENTAL HYGIENE PRACTITIONER? Comparable to a Nurse practitioner or Physician’s assistant, the ADHP would be a dental hygienist with a master’s degree who receives the additional training of a dental therapist This new oral health care provider has been developed by the ADHA Scope of practice would be preventive, diagnostic, and basic restorative to underserved populations in schools, nursing homes, community health centers, and dental clinics, under general supervision with standing orders from a dentist ADHPs will receive four to six years of education and be licensed Practice could involve either private practice or safety net clinics, where Medicaid would be accepted, increasing access to care and permitting the ADHP to treat pts and refer as needed to the dentist Practice could also involve general supervision in underserved areas

17. HOW CAN THE ADHP MODEL BE IMPLEMENTED? Consensus building – keep stakeholders focused on improving access to oral health to the underserved Legislation – work with the State Board of Dentistry to permit implementation of a new provider under existing regulations or enact new legislation to establish the new provider model Regulation – determine whether an existing board or a new board or committee needs to be established Education – curriculum development, funding, faculty training, accreditation System level changes – determine where new providers will work and develop business plans, marketing, contracts, collaborative agreements with dentists

18. WHAT ARE OTHER STATES DOING? Tools for workforce development California The Health Workforce Pilot Projects Program conducted evaluations to inform legislators about the strengths and weaknesses and how new providers would fit into the system. RDHAP was tested in1980 to teach new skills and expand the role of dental hygienists. In 1997, the new category was signed into law and 231 RDHAPs are in practice in California. Colorado In 2008, the governor commissioned a study on expanding the scope of practice of advanced practice nurses, physician assistants, and dental hygienists. The report concluded that unsupervised hygienists can competently provide preventive services within their scope of training, education, and licensure.

19. WHAT ARE OTHER STATES DOING? Tools for workforce development Iowa The Bureau of Health Care Access in the Iowa Dept of Public Health was established to address overall health care planning, including oral health. Legislation in 2007 and 2008 has enabled data to be continuously gathered and reported to the governor regarding workforce recommendations, recruitment, and retention of health professionals. Minnesota In 2008 the Omnibus Higher Education Policy Bill established the Oral Health Practitioner, similar to the ADHP. The Commissioner of Health and the Board of Dentistry met to make recommendations regarding the education, training, scope of practice, licensure, and regulation. In May 2009, the new provider was established and signed into law.

20. WHAT IS THE ADVANCED DENTAL THERAPY (MSADT) PROGRAM? Master of Science in Advanced Dental Therapy, Metropolitan State University, Minnesota The FIRST and ONLY Program in the U.S. Pre-requisite: Baccalaureate educated licensed dental hygienist Results in dual licensed, midlevel provider: dental hygienist and dental therapist Full time, graduate program, 44 credits Admissions criteria include:  GPA 3.0  Current Minnesota RDH license with nitrous oxide and local anesthesia certifications  Prerequisite course – Restorative functions theory and lab

21. WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ? The science of health care delivery phase focuses on:  Working within diverse communities  Communication across cultures  Understanding health care needs and the incidence of disease across populations  Advancing safe, quality oral health care  This phase has a total of 8 credits The clinical practice development phase focuses on:  Advancing assessment and evaluation skills and knowledge  Simulation and clinical experiences  Collaborative care provision skills unique to advanced dental therapy  This phase has a total of 31 credits The leadership and synthesis phase concentrates on:  Extending health system and public policy knowledge  Developing leadership skills  A capstone project focused on the evaluation of a relevant clinical question  This phase has a total of 5 credits

22. WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ? MSADT Inter-professional Didactic Courses NURS 608 Epidemiology NURS 605 Health Policy and Leadership HSCI 648 Designing for Quality in Health Care COMM 533 Theories and Explorations in Community-Based Intercultural Communication These courses may be taken prior to or during completion of the MSADT competency- based dental courses.

23. WHAT COURSES ARE REQUIRED FOR THE ADVANCED DENTAL THERAPY (MSADT) ?) MSADT Competency-Based Dental Courses DENH 610 Health Assessment and Oral Diagnostic Reasoning DENH 620 Pharmacology Principles of Clinical Application DENH 630 Management of Dental Emergencies and Urgent Care DENH 640 Community-Based Primary Oral Healthcare I DENH 650 Community-Based Primary Oral Healthcare II DENH 660 Community-Based Primary Oral Healthcare III DENH 670 Community-Based Primary Oral Healthcare IV DENH 680 Community-Based Primary Oral Healthcare V DENH 690 Advanced Specialty Practices DENH 700 Advanced Community Specialty Internship DENH 710 Comprehensive Competency-Based Clinical Capstone

24. WHAT IS THE EXPANDED SCOPE OF PRACTICE FOR ADVANCED DENTAL THERAPIST (MSADT) ? Provide diagnostic services Formulate care plans Prepare and restore primary and permanent teeth Provide palliative therapy Emergency temporary placement of crowns Placement of preformed crowns Temporary restorations

25. WHAT IS THE EXPANDED SCOPE OF PRACTICE FOR ADVANCED DENTAL THERAPIST (MSADT) ? Pulpotomies on primary teeth Direct and indirect pulp capping Prescribe medications Non-surgical extractions Identify orthodontic problems and refer Provide referral for dental tx beyond the ADHP scope of practice

26. WHICH PROCEDURES WILL THE ADVANCED DENTAL THERAPIST (MSADT) NOT PERFORM? Perform root canals Prepare and place permanent crowns Prepare and place bridges Construct dentures Place dental implants Perform whitening or cosmetic procedures Preform surgical procedures

27. WHAT ELSE WILL IMPACT THE PRACTICE OF THE ADVANCED DENTAL THERAPIST (MSADT) ? The ADHP is NOT an independent practitioner The ADHP works under general supervision in collaboration with a dentist

28. HOW IS THE FIRST DENTAL THERAPIST IN MINNESOTA PRACTICING? Works in collaboration with a dentist Makes about half of what the dentist makes Has approximately two more years of education than a hygienist but two less than a dentist Is licensed to replace crowns, extract teeth, and provide restorations Works in an office where 50% of the pts are low income Treats pts that many dentists will NOT treat because of the low reimbursement rates for pts on public assistance

29. WHAT MAY BE HAPPENING AT THE ADA / ADAA ANNUAL SESSION IN NEW ORLEANS? CODA is NOT planning accreditation standards for a hygiene based dental therapy program at this time CODA has a draft for accreditation standards for non-hygiene based dental therapy program Minnesota has a dual track program, legislative proposals for Washington and Vermont are dual track, and Kansas’ is hygiene based. Currently, the only state seeking dental therapy accreditation is Minnesota (the Minnesota Board of Dentistry has approved both the dental therapist and advanced dental therapist programs). The Commission needs to develop dental therapy standards for practitioners with a dental hygiene degree.

30. HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE? 14 million children enrolled in Medicaid did NOT receive any dental service in 2011 In 22 states, less than half of Medicaid enrolled children received dental care in 2011 A 2009 survey by the ADA revealed 37% of dentists are over age 55. ADA projects that between 2010 and 2030, the ratio of dentists to Americans will continue to fall Delaware has a dental shortage resulting in 21.9% of the population underserved

31. HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE? Vermont and Maine each have over 48% of their dentists over age 55 (NJ has 36% and NY 37%) By 2014, it is projected that the Affordable Care Act will provide dental coverage for an additional 19 million children BUT they will be entering a system that is unable to provide dental care for all the children with coverage Dentists reasons for not accepting Medicaid include low reimbursement rates and burdensome administrative procedures

32. HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE? In NY, 57% and in NJ 51% of Medicaid enrolled children did NOT receive dental care in 2011 In 2009, > 830,000 Americans visited a hospital ER for toothaches Previously, in 2006, decay related ER visits cost $110,000 million Workforce Expansion: 15 states, including KS, MA, ME, NH, NM, VT, and WA are considering legislation to expand the scope of practice for hygienists and to license mid-level providers such as dental therapists

33. HOW DO SHORTAGES LIMIT CHILDREN’S ACCESS TO CARE? A 2012 survey of deans of dental schools found that 75% thought that the scope of practice for hygienists and assistants should be expanded Mid-level providers may make it financially feasible for private practice dentists to treat more low income patients They may also serve in rural clinics, low income schools, and work with Telehealth Technology which links the supervising dentist to the mid-level provider In Minnesota, dental therapists are employed in nonprofit dental clinics and community health centers In Alaska, mid-level providers treat 35,000 rural residents

34. OUR FUTURE? What should we be planning for New Jersey, New York, Pennsylvania, and Connecticut ?

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37. REFERENCES Ervin, Anthony J., What is an articulation agreement? Retrieved July 15, 2013 from http://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation- agreement.htmhttp://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation- agreement.htm http://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation- agreement.htmhttp://www.nextstepu.com/plan-for-college/college-transfer/what-is-an-articulation- agreement.htm Featured Schools, retrieved 8/9/13 from PhDs.org., Copyright © 1997 – 2013 In Search of Dental Care, The PEW Charitable Trusts, retrieved 8/9/13 from http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/In_search_of_dental_care.pdf http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/In_search_of_dental_care.pdf KEAN UNIVERSITY AND BERGEN COMMUNITY COLLEGE NURSING EDUCATION PARTNERSHIP PROGRAM 2012 – 2013, retrieved 8/9/13 from http://www.bergen.edu/pages1/Documents/81512_REVISED%20FINAL_COPY_OF_KEAN_BCC_ADMISSION _BOOKLET_R_MC_VH_111611.pdf http://www.bergen.edu/pages1/Documents/81512_REVISED%20FINAL_COPY_OF_KEAN_BCC_ADMISSION _BOOKLET_R_MC_VH_111611.pdf NJ College 2 College Transfer, retrieve July 15, 2013 from http://www.njccc.org/college2college/4yearcolleges.htmlhttp://www.njccc.org/college2college/4yearcolleges.html

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