Identifying Vulnerable Populations: Who is Primary Care?

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Identifying Vulnerable Populations Who is
Primary Care?

• Ginny Cathcart BA, Dip. DH, M.Ed. RDH

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Why The Visioning Summit?

• Dental hygienists have much to offer the public
  in terms of education, health promotion,
  preventive therapeutic care.
• The public has few choices for service delivery
  models when it comes to accessing dental hygiene
  care.
• The private system of dental care is often the
  only choice.
• For many citizens this system is not an option
  due to financial, physical, psychological or
  other barriers.

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Alternative Service Delivery

• To achieve improved levels of oral health for a
  broader segment of the population, new models of
  dental hygiene service delivery need to be
  developed.
• You were invited to this Summit to begin the
  process of developing alternate service models
  which take full advantage of the dental
  hygienists broad range of skills to enhance the
  oral health of the public.
• The focus will be on serving segments of the
  population who are currently underserved such as
  the poor, the dental phobic, the homebound and
  the institutionalized.

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Anticipated Outcomes

• A vision of alternate service and its relevance
  to the future of the dental hygiene profession.
• Identification of those clients and users who may
  access alternate service delivery.
• Discussion of a range of potential alternate
  service models
• Agreement on the next steps for BCDHA and the BC
  Dental Hygiene Educators to work cooperatively in
  actualizing proposals for alternate service
  delivery
• Agreement on concrete responsibilities and
  timelines for implementing alternate delivery
  models.
• The summit final report will be available to
  BCDHA members.

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Mapping the issues?

• Who lacks access to dental hygiene services?
• Who cares about access to care?
• Why is access denied?
• Is primary care a turf conflict?
• Who is primary care?
• Why vision alternatives?

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Dental Hygiene Process of Care?

• Is primary care just the full process of care
  taught in current dental hygiene programs?
• Is our current dental hygiene education
  sufficient for accessing vulnerable populations?
  (2)

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Primary care Features and disciplines

• Definitions of primary care are numerous and
  either more descriptive or normative, depending
  on the purpose they serve.
• The normative approach has been closely connected
  with the WHO Alma Ata Declaration in 1978 on
  Primary Health Care, in which the focus was on
  solidarity and equitable access to care (1)

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Primary care features and disciplines

• on the protection and promotion of health rather
  than on curing illness
• on more influence of the population on health
  care instead of professional dominance
• and on broad intersectoral collaboration in
  dealing with community problems (WHO, 1978) (1)

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Who is Primary care?

• One consistent thread within these variations is
  that primary care consists of the professional
  response when patients make first contact with
  the health care system. (1)

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The primary care process

• The attributes or functions of primary care have
  been concisely summarized in the definition of
  the American Institute of Medicine (Donaldson et
  al., 1996) referring to
• the provision of integrated, accessible health
  care services by clinicians who are accountable
  for addressing a large majority of personal
  health care needs,
• developing a sustained partnership with patients
  and practicing in the context of family and
  community (1)

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Responsiveness to community needs is a key
element of primary health care.

• Therefore, the range and configuration of
  services may vary from one community to another.
• There is no "one size fits all" model.
• Similarly, there may be various governance and
  funding models. (1)

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Vision the Solutions

• a greater emphasis on health promotion and
  illness/injury prevention
• voluntary participation by providers and patients
  alike (2)

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Vision the Solutions

• capacity-building in evaluation, so that system
  performance may be monitored and
• an explicit focus on change management activities
  to support all of the above. (2)

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Supports to primary health care

• information technology (especially electronic
  health records)
• governance and funding models which support
  team-based care
• links to public health and
• a culture of accountability, performance
  measurement, and quality improvement. (2)

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The neglected epidemic

• Poor children,
• the elderly,
• developmentally disabled,
• the medically compromised,
• homebound and homeless people,
• those with HIV,
• uninsured,
• institutionalized individuals,
• as well as members of ethnic minorities,
• remain most vulnerable to oral diseases. (3)

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The neglected epidemic

• The U.S. Surgeon General goes so far as to refer
  to a neglected epidemic because of the failure
  to recognize oral disease as a health priority in
  the USA.
• Report offers Canadian health officials and
  caregivers an unprecedented opportunity to
  learn(3)

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Low Income Families

• Many lack dental insurance and cannot afford to
  see private dentists.
• Many have no regular source of care. (3)

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Low Income Families

• Are less likely to have reliable private
  transportation
• Are more likely to rely, where its available, on
  public transportation
• Are more likely to have difficulties keeping
  appointments (3)

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Low Income Families

• Children from low income families are 50 less
  likely to have their dental caries treated than
  children from middle-income families.
• The consequences of untreated dental caries
  include pain, loss of appetite, mental
  distraction, tooth loss, disfigured smiles,
  speech pathologies, emotional distress, academic
  problems and behavioral issues. (3)

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The Elderly

• Often have income issues, transportation needs
  and care-giving conflicts.
• Federal health insurance plan for the elderly,
  offers no dental benefits in many areas.
• Institutionalized elderly have special access
  issues. (4)

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Canadian Seniors

• The dental care needs of Canadian seniors are not
  being met because of economic other barriers.
• Only 34 of Canadians, aged 65 and older,
  reported having visited a dentist in the last
  year.
• In contrast, 87.5 of them had visited a primary
  care physician a 2.5 fold difference.
• Alberta, the Yukon, and the Northwest Territories
  offer seniors dental care as part of their
  universal health care programs.
• Ontario and eight other provinces do not (4)

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Non-English Speaking Families

• Find it more difficult to learn about federally
  sponsored programs, get enrolled and locate
  participating providers
• Have difficulty communicating needs and problems
  to providers, understanding self-care
  instructions (3)

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Persons with developmental mental Disabilities

• Have greater dental morbidity than general
  population, less well-developed self-care habits,
  difficulty in making and keeping dental
  appointments, less compliant with treatment
  advice
• The mentally ill often use psychotropic drugs to
  manage their symptoms such drugs cause
  Xerostomia (dry mouth), which increases incidence
  of tooth decay and gum disease. (3)

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Under-represented persons

• First we need to address the needs of
• Low-income Canadians
• Seniors
• Aboriginal peoples (5, 6)

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CDHA urges the federal government

• to implement Medicare coverage for public dental
  hygiene programs for all low-income Canadians,
  particularly children and seniors, to narrow the
  ever widening gap in the oral health status
  between the rich and the poor. (5)

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CDHA the Federal Government

• needs to revise its reimbursement schedules for
  public oral health care services so that they are
  based on average market rates.
• This will improve access to oral health services
  for the neediest Canadians, who are presently
  refused treatment by some dentists who are
  reluctant to participate in public programs that
  in some cases provide reimbursements that do not
  cover their overhead costs. (5)

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CDHA recommends

• The federal government increase financial support
  for both the Community Health and the non-insured
  health benefits program (NIHB) of the First
  Nations and Inuit Health Branch of Health Canada,
  specifically for dental hygiene preventive
  programs, in order to reduce the gap in oral
  health between Aboriginal peoples and
  non-Aboriginal peoples. (5)

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The dental decay rates

• for Aboriginal peoples, which are three to five
  times greater than the non-Aboriginal Canadian
  population, show that the present funding for
  these programs is woefully inadequate.
• Poor access for aboriginal persons in Canada
• More likely to have untreated dental disease and
  they experience more severe consequences from
  dental disease. (5)

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Closer to home Cost to society to treat early
childhood caries BC

• Approx 1800 children are seen each year for
  dental treatment under general anesthesia at BC
  Children's Hospital (4-6 months wait time)
• Private dental care ranges 400-600
• The BC Dental Association advocates a private
  public partnership, where the health ministry
  pays the facility fee for displaced children in
  private clinics. (7)

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What This Means?

• Much is written about minimal access to care once
  oral diseases are developed.
• The panellists will assert that access to
  optimal, primary oral healthcare must occur
  before oral disease develops.
• Review WHO definition of Primary Care (1)

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Fair Access to Oral Health

• apply research outcomes oral health policy on
• the protection and promotion of health rather
  than treating disease
• more influence of the population on health care
  instead of professional dominance
• On interprofessional collaborations in dealing
  with community problems (1)

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What This Means?

• Panellists keynote speaker will present
  alternative service delivery
• Population health
• Social marketing
• Mentoring applied research
• Interprofessional collaborations
• Expanded full scope of practice
• Dental hygiene primary care

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References

1. Saltman RB, Rico A Boerma WGW (Eds). Primary
   Care in the drivers seat? Organizational Reform
   in European Primary Care. Open University Press
   McGraw-Hill Education McGraw-Hill House.
   Berkshire, England, New York, NY. 2006 cited
   19-Apr-07 at http//www.euro.who.int/Information
   Sources/Publications/Catalogue/20060403_3
2. About Primary Care Health Canada. Cited
   1-Apr-07 at http//www.hc-sc.gc.ca/hcs-sss/prim/
   about-apropos/index_e.html
3. Herenia P. L. James L. L., The U.S. Surgeon
   Generals Report on Oral Health in America A
   Canadian Perspective. J Can Dent Assoc 2001 67
   (10) 587. cited 19-Apr-07 at
   http//www.cda-adc.ca/jadc/vol-72/issue-8/vol72_is
   sue8.pdf

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References

• 4. Leake, JL The History of Dental Programs
  for Older Adults. J Can Dent Assoc 2000 66316-9
  cited 15-Apr-07 at
• http//www.cda-adc.ca/jcda/vol-66/issue-6/316.htm
  
• Ziebarth S. Financing Canadas Oral Health
  System. Oral Presentation to the House of Commons
  Standing Committee on Finance Pre-Budget
  Consultations. Canadian Dental Hygienists
  Association. 2002. cited 19-Nov-06 at
  http//www.cdha.ca/content/newsroom/pdf/Financing_
  Can_Oral_Health_Care_eng.pdf
• Dental Benefits available at http//www.hc-sc.gc.
  ca/fnih-spni/nihb-ssna/benefit-prestation/dent/ind
  ex_e.html
• BC Dental Association News Archive cited
  19-Apr-07 at http//www.bcdental.org/bcda/news/m
  ediaArchive-detail.jsp?item22

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Access to Oral Health Care On-line Resources

• Access Angst A CDHA Position Paper on Access to
  Oral Health Services 2003 at http//www.cdha.ca/
  pdf/position_paper_access_angst.pdf
• Access and Care Towards a National Oral Health
  Strategy. Presentations. University of Toronto.
  2004 at http//individual.utoronto.ca/accessandca
  re/saunderson.html
• Armstrong R. Access and Care Towards a National
  Oral Health Strategy Report of the Symposium.
  University of Toronto. 2004 at
  http//individual.utoronto.ca/accessandcare/Report
  .pdf

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Access to Oral Health CareOn-line Resources

• CDHA Newsroom News Releases at
  http//www.cdha.ca/content/newsroom/reports.asp
• Dental Hygiene Focus on Advancing the Profession.
  ADHA. 2005 at http//www.adha.org/downloads/ADHA_
  Focus_Report.pdf
• Leake, JL. Access and Care Reports from Canadian
  Dental Education and Care Agencies J Can Dent
  Assoc 2005 71(7)46971 at http//www.cda-adc.ca
  /jcda/vol-71/issue-7/469.pdf
• Main P, Leake J, Burman D Oral Health Care in
  Canada A View from the Trenches. J Can Dent
  Assoc 2006 72(4)319 at
• http//www.cda-adc.ca/jcda/vol-72/issue-4/319.pdf