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Forwarding Public Oral Health with Theoretically Framed Partnerships, Planning, Programs, and Policies

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Title: Forwarding Public Oral Health with Theoretically Framed Partnerships, Planning, Programs, and Policies


1
Forwarding Public Oral Health with Theoretically
Framed Partnerships, Planning, Programs, and
Policies
  • Amy Brock Martin, DrPH
  • Presentation to Public Health Consortium
  • October 15. 2013

2
Who we are
  • South Carolina Rural Health Research Center
  • 1 of 7 Rural Health Research Centers funded by
    the Health Resources and Services Administration
  • Administratively located in the Arnold School of
    Public Health at the University of South Carolina
  • Mission to increase knowledge of the persistent
    inequities in health status among populations of
    the rural US, with an emphasis on factors related
    to socioeconomic status, race and ethnicity, and
    access to healthcare services.

3
Presentation Overview
  • Introduce South Carolinas demonstration of the
    Academic Health Department Model through the
    Division of Oral Health (DHEC) and SC Rural
    Health Research Center (SCRHRC)
  • Guiding principles of partnership
  • Theoretically-driven State Oral Health Plan
  • Collaborative leadership model of SC Oral Health
    Advisory Council and Coalition (SCOHACC)
  • Results of AHD Model
  • Policy practice achievements
  • ROI (extramural funding)
  • Scientific contributions
  • Epidemiological impact
  • Rural disparities what we are doing about them

4
Why Public Oral Health Matters?
  • Oral health disparities hurt everyone!
  • Martin, AB et al. Dental Health Access to Care
    Among Rural Children, 2008, included in CD, also
    available at http//rhr.sph.sc.edu/report/(7-2)2
    0Dental20Health20and20Access20to20Care20Amon
    g20Rural20Children.pdf
  • What are costly diagnoses to your states
    Medicaid programs?
  • Those who come earlyPreemies
  • Huck O, Tenenbaum H, Davideau JL. Relationship
    between periodontal diseases and preterm birth
    recent epidemiological and biological data.
    Journal of Pregnancy, 2011, Article ID 164654.
  • Those who live longDementia/Alzheimers
  • Manczak M, Reddy, PH. Abnormal interaction of
    oliomeric amyloid-beta with phosphorylated tau
    Implications to synaptic disyfunction and
    neuronal damage. Journal of Alzheimer's Disease
    36(2), 2013, DOI10.3233/JAD-130275.
  • Those who with chronic diseaseDiabetes
    Cardiovascular Disease
  • Leite RS, Marlow NM, Fernandes JK. Oral health
    and type 2 diabetes. American Journal of
    Medical Science. 2013 Apr245(4)271-3.

5
Dental Health Professional Shortage Areas, 2012
6
Persistent Whole County Dental Health
Professional Shortage Areas, 2009 - 2012
7
Why Care About Safety Net Populations?
8
IOM Academic Health Department
  • IOM called for agency/academic partnerships to
    ensure the effectiveness of public health in 1988
    and 2003.
  • What is it?
  • According to ASPH, it is a partnership between a
    school of public health (SPH) and a health
    department to create a dynamic academic-practice
    collaboration, which effectively pools assets of
    both institutions.http//www.asph.org/UserFiles/A
    cademicHealthDepartments.pdf
  • HRSA determined poor responses by SPH agencies
    to IOM call to action in 2005.

9
South Carolinas SOHP Proof of Concept
  • DHEC and SCRHRC began partnership in 2006,
    facilitated by CDC Cooperative Agreement,
    Strengthen State Oral Disease Prevention
    Programs.
  • 15K contract codified relationship, which has
    leveraged 5.2 million in oral health grants and
    programs (excludes national research grants)
  • State Oral Health Plan (SOHP) as catalyst
  • A collaborative leadership model with SCOHACC
    used to develop 5-year SOHP
  • PRECEDE-PROCEED was used to facilitate the SOHP.

10
SOHP GENERAL THEORETICAL FRAMEWORK (Green and
Kreuter, 1999)
Phase 2 Epidemiological Assessment
Phase 1 Social Assessment
Phase 5 Administrative Policy Assessment
Phase 4 Educational Ecological Assessment
Phase 3 Behavioral Environmental Assessment
Phase 6 Program Implementation
Phase 7 Process Evaluation
Phase 8 Impact Evaluation
Phase 9 Outcome Evaluation
11
SOHP GENERAL THEORETICAL FRAMEWORK (Green and
Kreuter, 1999)
Phase 2 Epidemiological Assessment
Phase 1 Social Assessment
Phase 5 Administrative Policy Assessment
Phase 4 Educational Ecological Assessment
Phase 3 Behavioral Environmental Assessment
Phase 6 Program Implementation
Phase 9 Outcome Evaluation
Phase 7 Process Evaluation
Phase 8 Impact Evaluation
12
Partnership Guiding Principles
  • Funding opportunities should not drive the
    mission of DOH or SCOHACC
  • Remain focused on SOHP goals and objectives to
    avoid mission creep
  • Disseminate lessons learned through peer-reviewed
    venues
  • Focus on consensus building
  • Small funding opportunities should be used for
    credibility-building efforts that can be
    leveraged into larger, innovative grants
  • Respect partners expectations
  • e.g. academic needs for scholarly output, DHEC
    needs for epidemiological impact

13
Summary of Policy Practice Achievements since
2006
  • Act 235
  • Pew Rankings
  • Congressional testimony
  • NCSL Presentation
  • OB guidelines
  • School nurse dental screenings
  • Community water fluoridation advocacy training
  • Oral health integrated into Dept. of Ed. Health
    and Safety Standards
  • Early childhood guidelines
  • Fluoride varnish reimbursement policy (Medicaid)
  • AAPD/Head Start Dental Home Leadership State

14
Extramural Funding (5,220,000)
Grant Funding Amount Time Period Grantee
CDC State Infrastructure 1.5 million 2013-18 DHEC
HRSA Oral Health Workforce 1.5 million 2012-15 USC
DentaQuest Foundation 300,000 2012-14 USC
DQF Planning 100,000 2011-12 USC
CDC State Infrastructure 1.75 million 2008-2013 DHEC
Head Start Dental Home 10,000 2009-10 DHEC
ADA School Nurse Study 50,000 2009 USC
ASTDD Head Start Study 2,500 2007 DHEC
ASTDD CSHCN Study 7,500 2006 2008 DHEC
15
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16
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17
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18
ResultsScientific Contributions
  • Presented 12 posters and conducted 5 invited oral
    presentations at state and national conferences
    (APHA, Academy Health, Academy for Health Equity,
    NOHC, AAP, SCRHA, James E. Clyburn Health
    Disparities Lecture)
  • Published 2 manuscripts in peer-reviewed journals
    (Maternal Child Health Journal and Pediatric
    Dentistry) with 1 in development and 1 in RR
    (APHA Public Health Dentistry).
  • Influenced 3 national studies funded through the
    core RHRC grant
  • National Rural Childrens Oral Health Disparities
    Chartbook (2008)
  • State Policy Levers for Addressing Preventive
    dental Care Disparities for Rural Children (2012)
  • Dental Sealant Utilization Among Rural and Urban
    Children (2013)

19
OHNA Summary Results for 2012/2013Percent of
Children by Indicator
Weighted analysis for public schools in K and 3rd
grade. Sealants only include children in 3rd
grade.
20
Results Epidemiology Impact
21
Percent of Caries Experiences by Race/Ethnicity
2007 (plt0.0001 for race ethnicity not
calculated due to low observations) 2012
(plt0.0001 for race p0.01 for ethnicity)
22
Percent of Caries Experiences by Medicaid Member
Status
2007 2012 (plt0.0001)
23
Percent of Caries Experiences by Free Reduced
Lunch Participation
2007 2012 (plt0.0001)
24
Percent of Caries Experiences by Rural vs. Urban
School
2007 (plt0.0001) 2012 (p0.048)
25
Percent of Sealants by Race/Ethnicity
2007 (no race differences not calculated for
ethnicity due to low observations) 2012 (no race
differences p0.022 for ethnicity)
26
Percent of Sealants by Medicaid Member Status
2007 (plt0.0001) 2012 No differences
27
Percent of Sealants by Free Reduced Lunch
Participation
2007 2012 (No differences)
28
Percent of Sealants by Rural vs. Urban School
2007 2012 (No differences)
29
Percent of Untreated Caries by Race/Ethnicity
2007 (plt0.0001 for race not calculated for
ethnicity due to low observations) 2012 (No
differences for race or ethnicity)
30
Percent of Untreated Caries by Medicaid Member
Status
2007 (No differences) 2012 (p0.007)
31
Percent of Untreated Caries by Free Reduced
Lunch Participation
2007 (plt0.0001) 2012 (No differences)
32
Percent of Untreated Caries by Rural vs. Urban
School
2007 (plt0.0001) 2012 (p0.007)
33
Percent of Tx Urgency 1 by Race/Ethnicity
2007 (plt0.0001 for race not calculated for
ethnicity due to low observations) 2012 (No
differences for race or ethnicity)
34
Percent of Tx Urgency 2 by Race/Ethnicity
2007 (plt0.0001 for race not calculated for
ethnicity due to low observations) 2012 (No
differences for race or ethnicity)
35
Percent of Tx Urgency 1 and 2 by Medicaid Member
Status
2007 (No differences) 2012 (p0.0111)
36
Percent of Tx Urgency 1 and 2 by Free Reduced
Lunch Participation
2007 (plt0.0001) 2012 (No differences)
37
Percent of Tx Urgency 1 and 2 by Rural vs. Urban
2007 (plt0.0001) 2012 (p0.0083)
38
OHNA Takeawayshow do we see the glass?
  • Half Full
  • Caries experience has declined but disparities
    continue to exist
  • Untreated caries Tx urgencies drop is sizeable
  • race, ethnicity, and FRL disparities disappear!
  • Tx Urgency 2 is nearly eliminated
  • Half Empty
  • Sealants improve a little with lots left to do
  • Rural disparities remain throughout the
    indicators, except sealants

39
Addressing the rural disparities.
40
South Carolina Act 235 (2010)
  • Created the Community Oral Health Coordinator
    program (COHC) within DHEC.
  • work with school nurses in a targeted community
    program to improve dental health in the states
    public schools.
  • operate in three to five counties identified as
    dental health professional shortage areas. The
    program will provide dental health education,
    screening, and treatment referral for public
    school students in kindergarten, third, seventh,
    and tenth grades or upon entry into a South
    Carolina school.
  • provide community oral health education and
    training
  • coordinate transportation and other non-clinical
    support to patients and their families
  • link dentists who provide Medicaid services or
    would provide free or reduced-cost care to
    children identified by the screening that do not
    have a dental home
  • help ensure that parents understand the
    importance of not missing appointments and the
    need for follow-up care
  • provide a connection people in local communities
    with the tools they need to improve oral health
  • NO FUNDING APPROPRIATED!

41
HRSA Oral Health Workforce Grant
  • Teledentistry feasibility study
  • N387 (21.5 response rate)
  • COHC Training Center
  • Community Water Fluoridation Advocacy
  • Rural Safety Net Expansion

42
Perfect Storm of Opportunity
1. Oral Health 2014 Planning Grant
Sustainability Workgroup
2. MIECHV Grant
3. HRSA Oral Health Workforce Grant
43
Oral Health 2014 DentaQuest Foundation
  • System-Level Goals
  • To increase the number of dentists who see
    children aged 0 to 3 years
  • To increase the number of physicians who apply
    fluoride varnish
  • To integrate community oral health coordination
    into the SC Maternal, Infant, and Early Childhood
    Home Visitation program
  • Increase the knowledge of early childhood oral
    health needs among the aforementioned providers
    using Smiles for Life
  • Increase the knowledge of COHC techniques among
    existing care coordinators in community systems,
    e.g. WIC, BabyNet, FQHCs etc.
  • Person-Level Goals
  • Increase in the number of children aged 0 to 3
    years with preventive dental services
  • Increase in the number of children receiving
    fluoride varnish from their medical home
  • Decrease in early childhood caries-related
    treatment
  • Increase parents perceived value of oral health
    services of children aged 0 to 3

44
How does DQF ask align with the SOHP?
PRECEDE-PROCEED
Organized in the Early Childhood Chapter
Parents, MDs, DMDs value oral health services
for 0-3
Improved appropriate use of preventive oral
health services
Parents engaged in care behaviors med/dental
interconnected
Safety Net Ed COHC Ctr Flu advocacy
DMD visit by 1 risk-based varnish received
Improved oral health for kids 0-3
Access to fluoridated water affordable, high
quality oral health services
Local fluoridation advocacy teams adequate care
capacity for 0-3
Engaged Stakeholder Collaboratives COHC through
MIECHV
45
How does our DQF ask align with Medicaid
priorities? Triple Aim Model
Source Berwick DM, Nolan TW, Whittington J.
The Triple Aim Care, Health, and Cost. Health
Aff. May 2008. 27(3)759-69.
  • Achievement of Triple Aim is contingent upon the
    following conditions
  • Focus on a specific population
  • Consistency in approach/care for the specified
    population
  • Use of an organization (an integrator) that
    accepts responsibility for all three aims for
    that population. Berwick et al states the
    integrators role includes at least five
    components
  • partnership with individuals and families,
  • redesign of primary care, (in our case, oral)
  • population health management,
  • financial management, and
  • macro system integration.
  • Improved population health
  • Reduction in early childhood caries
  • Improved care experience
  • DMD visit by age 1 with annual visits thereafter
  • Receipt of risk-based fluoride varnish
  • Decreased per capita costs
  • Increased overall savings to Medicaid due to
    increase in preventive service utilization

46
Unanticipated Benefit
  • Public Health Leadership Development
  • Martin obtains public oral health practice
    experience
  • Former DOH Director (Veschusio) obtains technical
    training by entering the HSPM DrPH program
  • We have trained 7 graduate students with DOH
    through public health practica and graduate
    assistantships.
  • Valeria Carlson (HPEB) works for CDC
  • Gerta Ayers (HSPM) works for DOH and is currently
    interim director

47
Summary Facilitators of Success
  • Deliberate (usually) delivers!
  • Theoretically-driven strategic plan
  • Mutually agreed upon guiding principles and
    expectations
  • Data-driven solutions
  • Leadership development

48
Contact information
  • Amy Brock Martin, Dr.P.H.
  • brocka_at_mailbox.sc.edu
  • SC Rural Health Research Center
  • 220 Stoneridge Drive, Suite 204
  • Columbia, SC 29201
  • 803-251-6317 (telephone)
  • http//rhr.sph.sc.edu
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