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Identifying Vulnerable Populations: Who is Primary Care?


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Title: Identifying Vulnerable Populations: Who is Primary Care?

Identifying Vulnerable Populations Who is
Primary Care?
  • Ginny Cathcart BA, Dip. DH, M.Ed. RDH

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
  • 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.

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
  • 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.

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
  • Agreement on concrete responsibilities and
    timelines for implementing alternate delivery
  • The summit final report will be available to
    BCDHA members.

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?

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?

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)

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)

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)

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)

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)

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

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)

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)

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)

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

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

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

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)

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)

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
  • 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)

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)

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
  • 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)

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

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)

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)

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)

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)

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)

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)

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)

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

  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//
  2. About Primary Care Health Canada. Cited
    1-Apr-07 at http//
  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

  • 4. Leake, JL The History of Dental Programs
    for Older Adults. J Can Dent Assoc 2000 66316-9
    cited 15-Apr-07 at
  • http//
  • 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
  • Dental Benefits available at http//www.hc-sc.gc.
  • BC Dental Association News Archive cited
    19-Apr-07 at http//

Access to Oral Health Care On-line Resources
  • Access Angst A CDHA Position Paper on Access to
    Oral Health Services 2003 at http//
  • Access and Care Towards a National Oral Health
    Strategy. Presentations. University of Toronto.
    2004 at http//
  • Armstrong R. Access and Care Towards a National
    Oral Health Strategy Report of the Symposium.
    University of Toronto. 2004 at

Access to Oral Health CareOn-line Resources
  • CDHA Newsroom News Releases at
  • Dental Hygiene Focus on Advancing the Profession.
    ADHA. 2005 at http//
  • Leake, JL. Access and Care Reports from Canadian
    Dental Education and Care Agencies J Can Dent
    Assoc 2005 71(7)46971 at http//
  • 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//