1. Dental Health Aide Therapists
Bringing Oral Health Care into the 21st Century
NPAIHB QBM
wednesday, october 28, 2015
Pam johnson, Oral Health Project specialist
Hello,
My name is Christina Peters, I am the oral health project director for the Northwest Portland Area Indian Health Board and I’m very pleased be here with you today to talk to you about one of my favorite subjects, Dental Health Aide Therapists.

2. Oral Health is important to overall health
yet millions of people living in tribal communities cannot get the dental care they need.
We know that Oral Health in Important to Overall Health and we cannot have healthy communities without access to reliable, high quality, culturally competent dental care.
And yet:
Tooth decay in children is one of the major health problems in the United States – especially among low-income and minority populations;

3. A Solution: Dental Health Aide Therapists
Model began in the 1920s
Dental therapists practice in 54 countries, including the US, Canada, England, Australia, New Zealand and The Netherlands
Under supervision of dentists, dental therapists can practice in remote
And we are doing this by expanding the dental team to include Dental Health Aide Therapists.
Much like PAs and NPs have done for medicine. - and much like when PAs and NPs first came into being, we are fighting with established dentistry who is working very hard to spread misinformation and scare people from this viable and safe innovation in oral health care delivery.
Dental therapists can extend care to our tribal communities and help dentists see more patients
This is a proven model of providing routine and preventive care in community settings that has expanded care to over 45,000 Alaska natives and is working in many other countries.
Under supervision of dentists, dental therapists can practice in remote settings where there is need for additional provider capacity
Evidence shows that the care provided by dental therapists is high quality, cost effective and safe
Dental Therapists currently practive in tribal communities in Alaska and statewide in Minnesota.
settings where there is need for additional provider capacity
Evidence shows care provided by dental therapists is high quality, cost effective and safe
History of providing routine and preventive care in community settings

4. Dental Therapists Primary oral health care professionals
Basic clinical dental treatment and preventive services
Multidisciplinary team members
Advocate for the needs of clients
Refer for services beyond the scope of the DHAT’s practice
Dental Therapists are primary oral health care professionals.
84.7% of the care that dental therapists provide is routine and preventive –
28.2% evaluation and assessment;
23.7 – restorations (filling cavities).
Extractions just 3.8% of procedures done by dental therapists.
Dental therapists are providing routine and preventive care – evaluating problems, putting on fluoride varnish, placing sealants; performing kids prophys; and filling cavities.
They are doing the routine and preventive care that will prevent people from showing up in emergency rooms and having to deal with costly care in the future.
32.8% prevention;

5. Dental Therapists in Action
Alaska’s Dental Therapists
35 dental therapists increased access to care for over 45,000 Alaska Natives
Provide culturally competent care
Produce high patient satisfaction rates
Reduce amount of emergency care
Increase preventive care
Create jobs and generate economic impact
Created 76 full time jobs per year with total personal income of $4.4 million
Net economic effect of program is $9.7 million in Rural Alaska
In AK DHATs are largely in rural, underserved communities. Many of the communities are accessable only by plane - so remote supervision is very important.
There 35 dental therapists have increase access to dental to care to over native Alaskans
78% of dental therapists practice in their village or region of origin;
87% of Dental Therapists are AI/AN
Retention rate: 81% over 10 years;
There is a High patient satisfaction
Median Age: 34, age range is 23-57
Demographics: 80% female/ 20% male, 88% native/ 12% Caucasian.
You can compare that to The average Oregon dentist was 58.8 years old in rural Oregon and in a 2010 poll, about 18 percent of Oregon's rural dentists polled in the 2010 report said that within the following two years they planned to either reduce patient care hours, retire, move to work in another state or leave dentistry all together. 
Educational program completion rate: 64% (US 2 year college completion rate about 30%)
Percentage of DHATs practicing in their village of origin or region of origin: 78%
Retention rate: 81% over 10 years
Swinomish Dentist Rachael Hogan observes DHAT Savannah Bonorden on a recent learning trip to Sitka, AK

6. Why no DHATs in lower 48???
After losing the battle in Alaska to prevent DHATs from expanding services to Tribal communities, the American Dental Association was successful in inserting the following language in the re-authorization of the Indian Health Care Improvement Act:
Expansion of the Community Health Aide Program “shall exclude dental health aide therapist services from services covered under the program…”
“…shall not apply in the case of an election made by an Indian tribe or tribal organization located in a State (other than Alaska) in which the use of dental health aide therapist services or midlevel dental health provider services is authorized under State law…”

7. Swinomish Indian Tribal Community DHAT Initiative
Swinomish Chairman and NCAI President Brian Cladoosby announcing the Swinomish DHAT Initiative, June 2105

8. Swinomish Current Political and Legal Solution
-Swinomish Tribal Community worked for the past two legislative sessions with the Northwest Portland Area Indian Health Board and the Washington State House and Senate to craft a Tribal Specific DHAT Authorization Bill
-Lobbied heavily by the WSDA, no DHAT Bill—tribal or otherwise--got out of House or Senate Committees in Washington State for the past 10 years.
-Swinomish has determined that it has the power and obligation to address oral health systems change under Tribal Sovereignty -

9. Solutions for Swinomish Provided by DHAT
Procedure review for FY 2012, 2013 and 2014 for Swinomish Clinic showed that over 50% of procedures and services could have been provided by trained Dental Health Aide Therapist
Analysis shows that the same procedures could have been covered with 50% Personnel cost savings-replace Dentist time with DHAT time
DHAT Licensure Authorization would help I/T/U Clinics fill a huge gap in service demand across the Indian Health Service system for Native patients
Work Force Development strategy of a DHAT based in the Community assures longer term Community and Public Health benefits

10. Our Current Systems Solution
-Swinomish has adopted 2 Tribal laws under its own regulatory framework:
It has created a Division of Licensing, roughly equivalent to the State of Washington’s and
It has adopted a Dental Health Provider Licensing Code under which Dentists, Dental Hygienists, and Dental Health Aide Therapists will be licensed

11. History being made!
Swinomish Dental Health Provider Licensing Board and Staff: Dr. Rachael Hogan, Board Member; Stephen LeCuyer, SITC Staff Attorney; Tara Satushek, SITC Associate Planner; Ed Knight, SITC Director Division of Licensing; John Stephens, SITC Programs Administrator; Dr. Louis Fiset, Board Member; Brian Wilbur, Board Member. Board members not pictured: Ruth Ballweg and Diane Vendiola.

12. Building a 21st Century Dental Team!
Swinomish has entered in to a Interlocal Agreement with the Alaska Native Tribal Health Consortium to provide DHAT Training to Swinomish members accepted into the program. The first trainee started the program this July, and after graduating in 2017 will come back to serve her community.
Aiyana Guzman, SITC,
Class of 2017

13. DHAT services begin in January 2016
Daniel Kennedy, experienced DHAT currently working for the Southeast Regional Health Consortium in Alaska will be joining the Swinomish Dental Clinic Team!

14. Analysis of the Swinomish Solution
-The Swinomish Solution is a huge step forward in advancing DHATs and dental therapists in the lower 48.
-Swinomish Solution develops a “replicable Tribal Model” under Tribal Sovereignty
-Unfortunately the Swinomish Model cannot be duplicated by all Tribes, especially resource poor tribes
-State Legislatures still need to authorize DHATs, especially in Tribal settings under current IHCIA language!

15. Oregon Tribes DHAT
Pilot Project

16. ackground
Oregon Dental Pilot Projects were authorized by state legislation in 2011 to increase access and improve quality to oral health care by:
Teaching new skills to existing providers,
Developing new categories of dental providers, and
Accelerating and expanding the training to current providers.

17. This year, 2015, legislation was passed to:
Extend the sunset date from 2018 to acknowledging the slow start and lack of funding to the program since 2011
Make sure new providers and services would be covered by Medicaid
Oregon Health Authority funded for upcoming year to administer the program

18. The Northwest Portland Area Indian Health Board, working with Oregon tribes, has submitted a dental pilot project to the Oregon Health Authority to train and employ DHATs at Tribal Health and Dental Clinics. Proposed outcomes of the pilot are to:
Expand access to consistent, routine, high quality oral health care in tribal communities;
Grow the number of AI/AN oral health care providers available to tribal communities;
Bring culturally competent care into tribal communities;
Create a more efficient and effective oral health team that can meet the needs of the tribal communities;
Establish cost effective solutions to oral health challenges in tribal communities;
Bring care where it is needed most.

19. Initial Pilot Sites Coquille Indian Tribe
Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians
Coquille Indian Tribe

20. Pilot Project Application
First Pilot Project submitted to the state: Project 100!
The application includes a full summary of project, training program, employment options, patient notification, evaluation and monitoring plan, and costs
Last week it was deemed “complete” and sent to a Technical Review Board for a 30 day review.
Final decision rests with the OHA Dental Director
While we are moving forward with both of these sites to prepare for a DHAT program, one critical step is applying for and getting approval from the state for the projects. This is the authority by which a DHAT can practice in Oregon.

21. Next Steps
Work with pilot tribes to start informing and educating the tribal community about adding a DHAT to the dental team.
Start recruiting 2nd DHAT student from CTCLUSI and 1st DHAT student from Coquille for July 2017 start of training
Initiate training for the supervising dentist at CTCLUSI
Start recruiting an experienced DHAT to begin providing services at dental clinic in mid-2017
Explore setting up a regulatory structure/licensing code similar to Swinomish

22. Building a 21st Century Dental Team!
Confederated Tribes of Coos, Lower Umpqua and Siuslaw Indians has entered in to a Interlocal Agreement with the Alaska Native Tribal Health Consortium to provide DHAT Training to CTCLUSI members accepted into the program. The first trainee started the program this July, and after graduating in 2017 will come back to serve her community.
Naomi Petrie, CTCLUSI
Class of 2017

23. Northwest Portland Area Indian Health Board
For more information please contact:
Christina Peters, Oral Health Project Director
Pam Johnson, Oral Health Project Specialist
Indian Leadership for Indian Health