1. Summary of Surveys: Families, Dentists and School Nurse Administrators Children’s Oral Health Coalition August 2011

2. The COHC mission is to improve the oral health of children in Tarrant County. The COHC vision is that all children in Tarrant County, with a focus on children ages birth through third grade, will receive preventive dental education and preventive treatment, emphasizing good oral hygiene. Children in Title 1 schools with severe dental problems will receive dental care and comprehensive preventive dental education. * Title 1: Free/reduced lunch rate schools

3. The Children’s Oral Health Coalition (COHC), led by Cook Children’s Community Health Outreach department, seeks to improve the oral health of children in Tarrant County with a key focus on underserved children. Organized in 1999, the COHC is a diverse, county-wide collaboration. Members from more than 35 local organizations have joined the COHC to promote awareness of children’s oral health issues and support the prevention of oral health disease.

4. 4 Purpose of Surveys Within a five month period in 2002, three groups were surveyed to gather information and assess perceptions regarding the state of oral health in Tarrant County disadvantaged children: families, dentists and school nurse administrators. In 2005, 2008 and 2011 these groups were revisited to determine if progress had been achieved toward improving oral health in disadvantaged children. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

5. 5 Survey Parameters 1. Dentist survey (Tarrant County dentists) 2011: Survey mailed to 645 dentists in May, 155 responded. Reminder sent subsequently as an online option was made available 2008: Survey mailed to 221 dentists in July, 65 responded Online survey also emailed to 372 dentists in July, 112 responded 2005: Survey mailed to 612 dentists in October, 172 responded 2002: Survey mailed to 612 dentists in July, 200 responded 2. Nurse administrator survey (nurse administrators in Tarrant County ISDs) 2011: Online survey emailed to 17 administrators in April, 13 responded 2008: Online survey emailed to 16 administrators in June, 12 responded 2005: Survey mailed to 17 administrators in December, 16 responded 2002: Survey mailed to 17 administrators in October, 13 responded Note: Masonic Home ISD is no longer a Tarrant County school district, leaving 16 ISDs in 2008 3. Family Surveys (neighborhood clinics) Four Cook Children’s Neighborhood Clinics were surveyed in 2002, 2008 and 2011. The surveys were provided in both Spanish and English. Four WIC clinics were surveyed in 2005 because two of the neighborhood clinics had closed between 2002 and 2005. WIC clinics serve clientele similar to the neighborhood clinics. 2011: Survey distributed to families at four Cook Children’s Neighborhood Clinics (Northside, Miller, Arlington and McCart) in May, 414 responded 2008: Survey distributed to families at four Cook Children’s Neighborhood Clinics (Northside, Miller, Arlington and McCart) in July, 391 responded 2005: Survey distributed at four WIC clinics (Fiesta Plaza, Southside, Miller and New York Street) in December, 417 responded 2002: Survey distributed at four Cook Children’s Neighborhood Clinics (Central, Miller, Northside and Arlington) in December, 421 responded Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

6. 6 Do any of your children have dental pain or dental problems that are not being treated? Finding: Children in pain dropped below 10% in 2011. Responses: 2002: 417 2005: 408 2008: 387 2011: 413 Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

7. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 7 Do you have a dentist that your children see regularly? Finding: Many more children see a dentist regularly compared to the previous three surveys Responses: 2002: 414 2005: 398 2008: 391 2011: 410

8. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 8 Who provides your dental insurance? Finding: Significant increase in families using Medicaid in 2011 Responses: 2002: 407 2005: 386 2008: 379 2011: 381

9. Are you currently a Medicaid provider? 2005 Respondents=168 2002 Respondents=200 2002: Yes: 16% No: 84% 2005: Yes: 16% No: 84% Responses: 200 168 177 152 Finding: Percent of Medicaid providers doubles since 2002 Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 9 If so, are you taking new Medicaid patients? Finding: Nearly all Medicaid providers are now taking new Medicaid patients Responses: 27 40 33 49

10. Why did you stop seeing Medicaid patients? 2005 Respondents=168 2002 Respondents=200 2002: Yes: 16% No: 84% 2005: Yes: 16% No: 84% Finding: Dropping Medicaid has become less of an issue in 2011 Note: Respondents can choose more than one factor Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 10

11. Are you currently a CHIP provider? 2005 Respondents=168 2002 Respondents=200 2002: Yes: 16% No: 84% 2005: Yes: 16% No: 84% This is a new question for 2008 Finding: Vast majority of dentists are not CHIP providers though a greater proportion of dentists are providers in 2011 Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 11 If so, are you taking new CHIP patients? This is a new question for 2008 Finding: Approximately 9 in 10 dentists are taking new patients 26 4 30 142 Responses: 2008: 172 2011: 150 Responses: 2008: 30 2011: 36 112 38 33 3

12. Why did you stop seeing CHIP patients? 2005 Respondents=168 2002 Respondents=200 2002: Yes: 16% No: 84% 2005: Yes: 16% No: 84% This is a new question for 2008 Finding: Reimbursement rate is the most common barrier though fewer dentists are citing reasons to stop seeing CHIP patients Note: Respondents can choose more than one factor Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 12 Responses: 2008: 35 2011: 15

13. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 13 How often are dental problems reported to your school nurses? Finding: Dental problems are reported on a daily basis at 17% of school districts and on a weekly basis at 43% of school districts Responses: 2002: 13 2005: 15 2008: 12 2011: 12

14. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 14 How common are dental problems in comparison with other health problems? Finding: Dental health declined in 2011 as a common health problem in comparison with other health problems. Responses: 2002: 12 2005: 16 2008: 12 2011: 12

15. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 15 How frequently does dental pain contribute to school absences? Finding: Dental pain is a top-ten absence problem in in a quarter of school districts Responses: 2002: 13 2005: 16 2008: 12 2011: 12

16. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 16 Do you have adequate community resources for referring low-income children for dental treatment? Finding: Adequate community resources is consistently lacking among respondents Responses: 2002: 14 2005: 15 2008: 12 2011: 12

17. How often do you encounter a child in need of a toothbrush? 2002: Yes: 16% No: 84% 2005: Yes: 16% No: 84% This is a new question for 2008 Finding: Children in need of a toothbrush is quite common Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011 17 Do you believe families have enough preventative oral health care for their children? This is a new question for 2008 Finding: Respondents found preventative education lacking though slightly improved in 2011 Responses: 2008: 12 2011: 12 Responses: 2008: 12 2011: 11

18. 18 Families 2011 80% of families report that their children see a dentist regularly and just 8% have children experiencing untreated pain. 91% of families surveyed have dental insurance through Medicaid or CHIP. 2008 More families (68%) say their children see a dentist regularly, but 18% still report children with dental pain not being treated. 82% of families surveyed have dental insurance through Medicaid or CHIP. 2005 Untreated dental pain has declined to 12%, but 42% still don’t see a dentist regularly. 2002 Although the majority of the families were insured through government programs, 20% had children with untreated dental pain and 44% of the children don’t receive routine dental care. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

19. 19 Dentists 2011 The number of dentists who are Medicaid providers continue to rise, now at 33% compared to 24% in 2008. This percentage has steadily risen since 2002. CHIP providers have also increased from 18% in 2008 to 25% in 2011. With both CHIP and Medicaid providers, the vast majority take new patients. 2008 The percent of Medicaid providers increased from 2005 to 2008. Dentists who stopped taking Medicaid cite paperwork and reimbursement rate as the most common issues. A new survey question for 2008 revealed only 18% of dentists are CHIP providers, citing reimbursement rate and inadequate benefits for patients as the most common issues. 2005 As in 2002, less than 20% of dentists are Medicaid providers and reimbursement rates again is the most important barrier for becoming a Medicaid provider. But since 2002, fraud legislation and failure to be paid have become increasing barriers to dentists seeing Medicaid patients. A small number of practices still see the bulk of Medicaid patients. 2002 Less than 20% of dentists who responded to our survey were Medicaid providers, with low reimbursement rates being listed as the most important single barrier. Of the dentists who accepted Medicaid patients, a very small number of practices see the bulk of the Medicaid patients. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

20. 20 School Nurse Administrators 2011 Dental problems are reported on a daily or weekly basis at 60% of school districts and is a Top 5 or 10 absence problem in 25% of school districts. 75% report it is not Top Ten problem. Adequate community resources seem to be improving as now only 67% deem them inadequate. 2008 Dental problems are reported on a daily or weekly basis at 83% of school districts and dental pain is a Top 5 or Top 10 absence problem in 34% of school districts. 66% report it is not a Top Ten problem. 92% report community resources for dental care lacking. 2005 62% of the nurse administrators report that dental problems are not a top ten health issue. Still, 75% report that community resources are not easily accessible and 66% report they are inadequate. 2002 Over half of the nurse administrators reported that dental problems are among the top ten of all student health problems and are reported on a daily or weekly basis. Over 75% of the nurse administrators reported that dental treatment resources are inadequate for low-income families and are not easily accessible. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011

21. 21 Conclusion Between 2002 and 2011, the number of dentists taking new Medicaid patients has increased. Yet, two-thirds still do not accept Medicaid and only a quarter are CHIP providers. Increasing awareness of the importance of dental health has driven regular dental visits to 80% of families surveyed. This has likely reduced untreated pain to 8%, which is substantially less than 20% measured in 2002. 59% of school nurse administrator surveyed in 2011 said dental health is a top-five or top-ten health problem, which is an improvement from 92% reported in 2008. While they also find community resources and preventive education for children severely lacking, the situation has improved from previous surveys. The number of dentists available to provide care to children covered by Medicaid and CHIP is critical because of the large number of eligible children in Tarrant County. There are 133,329 total Medicaid eligible children and 30,136 CHIP eligible children (under 15 years old) in Tarrant County. Source: System Planning and Community Health Outreach Departments at Cook Children’s, 8/2011