|
SPECIAL REPORTEstablishing, Funding, And Sustaining A University Outreach Program In Oral Health
The Surgeon General’s report of May 2000, Oral Health in America, suggests that there are two Americas in terms of oral health: those who have excellent oral health, and those who are unable to access care and have disparate amounts of dental disease. Since the majority of dental schools are located in urban settings, dental educators need to establish, fund, and sustain outreach programs while sensitizing students to the needs of the underserved. This paper describes the process that Case Western Reserve University School of Dental Medicine used to develop an outreach program to address the needs of underserved children in Cleveland, Ohio.
The Surgeon General’s report of May 2000, Oral Health in America, speaks of the importance of oral health in early medical intervention and to general health and well-being.1 During the past half-century, increased access to basic dental services, fluoridation of drinking water, and the availability of dental sealants have contributed to important gains in improving the oral health of Americans. However, despite these major improvements, profound and consequential oral health disparities exist within the U.S. population, especially among the poor. Two Americas exist in terms of oral health. One includes people who receive regular and preventive care from the dentist and have excellent oral health; the other includes those who are not able to access care and have disparate amounts of dental disease. The greatest indicator of this disparity is poverty, followed closely by racial, ethnic, and geographic indicators.2 The poor tend to lack both adequate dental insurance and the funds to cover out-of-pocket dental expenses. More than 150 million Americans have no or extremely limited dental coverage, and the number of untreated dental caries (tooth decay) among racial and ethnic minority groups is greater than the national average.3 Untreated dental disease is especially prevalent among children, with dental caries surpassing asthma and hay fever as the most common chronic childhood disease.4 Dental caries affects 18 percent of children ages two to four, more than half of children ages five to nine, and 61 percent of those age seventeen.5 Dental disease in children differs by income. Low-income children have twice as much dental caries as their more affluent peers do, and their disease tends to go untreated.6 In 1999 twenty million children and adolescents under age nineteen in families with low incomes accounted for 80 percent of tooth decay.7 Furthermore, the Ohio Department of Health named dental care as the leading unmet health care need for Ohioans.8 While Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit requires states to provide all Medicaid-eligible children under age twenty-one with comprehensive, preventive, restorative, and emergency dental services, only 20 percent of children who are deemed eligible for Medicaid actually receive preventive dental care each year.9 Eligibility for Medicaid does not ensure enrollment, and enrollment does not ensure that people obtain needed care.10 Public health and dental educators have found community outreach programs to be an increasingly effective solution for addressing unmet oral health needs. School-based programs have been deemed successful as a means of reaching underserved children.11 Also, dental schools have been making both voluntary and required community service projects part of their programs, with some even integrating them into the curriculum. If dental students are exposed early on to the oral health needs of the underserved, it is hoped that they will continue to provide care to those most in need when they become practicing dentists. This paper describes how Case Western Reserve University’s (Case’s) School of Dental Medicine established a school-based sealant program, funded the program, and is working to maintain funding. Preventive dental sealants are thin plastic coatings applied to the chewing surfaces of permanent molars to prevent tooth decay by creating a physical barrier against bacterial plaque and food. Sealant application is one of the earliest, least costly oral health interventions and is 100 percent effective in preventing certain cavities. However, less than 20 percent of children ages 5–17 have sealants.12 The Healthy Smiles Sealant Program, established in 1999–2000, is working to serve the oral health needs of second and sixth graders in the Cleveland Municipal School District (CMSD) through oral health education, services (oral exams and preventive dental sealants), and referrals.
When developing any outreach program, it is essential to conduct a comprehensive needs assessment and to gather input from all stakeholders who will be affected by the program. A common mistake is to develop a program that does not address existing needs and is not within the scope of the participating institutions’ missions. The CMSD’s chief executive officer (CEO) established the Health Leadership Council in September 2001, to develop a comprehensive plan to improve children’s health in the district. The council analyzed gaps in services and developed a plan. Both the director of Healthy Smiles and the president of the Saint Luke’s Foundation of Cleveland, which became Healthy Smiles’ primary funding partner, are members of the Health Leadership Council. Prior to 1999, the dental school conducted an in-house sealant program that transported CMSD students to the campus clinic for services. The program design had several drawbacks that included the following: travel-time constraints limited participation to only a handful of schools close to the university; the number of elementary/middle school children treated was small in relation to the total number of children in the district; bus capacity limited the number of children participating; and the entire process required students, along with a teacher, to miss two to three hours of class time. The outreach program was redesigned to deliver sealants through a school-based program. This change required the dental school and the school district to work through a number of legal and resource issues. The university’s attorneys examined possible liability issues regarding dental students and faculty supervisors’ setting up portable dental clinics and treating children in the schools. Open communication with the school district’s director of health and social services and school principals and nurses resolved how to provide services in school effectively, efficiently, and safely. The program’s objectives were to (1) target school children from low-income households with limited access to dental care, (2) perform dental exams and place sealants on healthy permanent molars, (3) teach children about dental hygiene and dental health, (4) refer children to area dentists or safety-net providers as needed, and (5) sensitize dental students to the needs of underserved children.
With the assistance of the University Development Office, contact was established with the Saint Luke’s Foundation, a local "new health" health care (conversion) foundation whose main mission is to "provide leadership and support for the improvement and transformation of the health and well-being of individuals, families and communities of Greater Cleveland."13 New health foundations, often formed when a conversion of a nonprofit health care organization to a for-profit provider occurs, are a growing philanthropic force. "State laws [when they exist] typically require converting organizations to preserve the charitable assets they accumulated as a result of their nonprofit status, often by endowing a new foundation."14 A survey by Grantmakers In Health identified 165 new health foundations nationally, with total assets exceeding $16.4 billion. After several initial meetings, the foundation encouraged the submission of a proposal for the school-based pilot program. The proposal described the critical need for a school-based sealant program and suggested a budget of $40,000 to buy six portable dental operatories and dental supplies. The funding approval by Saint Luke’s came shortly after the final approval from both the university and CMSD lawyers. A convenience sample of six Cleveland schools that had previously participated in the in-house sealant program would be included in the pilot program. If the pilot failed, the in-house sealant program would continue. Since permanent first and second molars are the teeth most likely to decay, second and sixth graders were targeted for sealant placement. With 100 percent of children in the district eligible to receive free breakfast and lunch (a commonly used indicator of low socioeconomic status), every child in the second and sixth grades was targeted for treatment. To encourage strong participation during the pilot phase, the CEO of the CMSD wrote a letter to parents endorsing the program. The letter was copied on the reverse side of the consent form, which required a parent’s signature prior to any treatment. During the 2000–01 school year, teams of third- and fourth-year dental students under the supervision of licensed dental school faculty brought portable dental operatories to the participating elementary and middle schools. All second and sixth graders with a signed consent form were educated individually on proper oral hygiene and nutrition and received an oral screening and sealants on all permanent molars that were free of decay. Children presenting with cavities, whether on the molars or elsewhere, or other oral health problems were referred to a community dentist or a safety-net provider. Partnering with the Forest City Dental Society—a chapter of the National Dental Association comprised of African American dentists in the Cleveland area—and the Greater Cleveland Dental Society, the Healthy Smiles Program provided students’ families with a list of local dentists willing to accept Medicaid payment or, in some cases, provide pro bono services for necessary restorative care. To encourage community dentists to accept the referrals, the dental school elected not to accept Medicaid reimbursement and allow the practitioners the opportunity to bill Medicaid. The dental clinics at the Case School of Dental Medicine, MetroHealth Medical Center, and North East Ohio Neighborhood Health Services agreed to serve as safety-net providers to meet the overflow volume of children. A dental referral coordinator was hired to work with school nurses in referring students to a community dentist or a safety-net clinic. The coordinator also followed up with the school nurse, parents, and community dentists as to the outcome of the referral.
With the success of the pilot program, as measured by the overwhelming acceptance by school officials and parents, the foundation encouraged the dental school to submit a second grant proposal to expand the program to include all Cleveland municipal schools. To serve the entire district, it was determined that it would take all four class years of dental students to participate. The clinical experience would need to follow a well-thought-out course intended to educate the dental students for their first experiential learning encounter. To get faculty buy-in, a faculty retreat was called to discuss the proposal. Faculty determined that the proposal should be submitted to the foundation after development of the necessary course with clinical experience. A seventy-two-hour course was developed, and a four-week block of time was dedicated to the school-based sealant clinical experience. The Saint Luke’s Foundation was impressed with the relatively quick turnaround of the grant proposal and the necessary change in curriculum. Not only was the grant proposal approved, but the foundation’s board voted to elevate the program from grant status to strategic initiative status. As one of three such initiatives within the foundation, Healthy Smiles was designated as an evergreen (continuous) funding program. The districtwide program is now in its third year of evergreen funding, with an annual budget of $550,000. The success of Healthy Smiles and continuous funding has led to additional funding and contributions. Procter and Gamble donates free toothbrushes, toothpaste, and instruction booklets to every child examined. Ultradent Products donates free sealant material for every one package purchased at the university’s discounted rate. In addition, the university provides storage space for the dental equipment, supplies, and vehicles at no charge. Additional grant requests were submitted to the Robert Wood Johnson Foundation (RWJF) and the Cleveland Foundation. To be eligible for the RWJF’s Local Initiative Funding Partners (LIFP) program, a program must be nominated by a local funder, which must also provide matching funds. Under the LIFP, the St. Luke’s Foundation sponsored the Healthy Smiles proposal to the RWJF to incorporate an oral health curriculum component. In August 2002 the RWJF awarded Healthy Smiles nearly $500,000 over a four-year period to initiate this education component directed to all second and sixth graders, their parents, teachers, school nurses, principals, and other administrators. A second grant ($120,000 over two years) for the education of pre-kindergartners through first graders was awarded by the Cleveland Foundation in September 2003. This second expansion was developed in response to the consistent finding that three-quarters of second graders examined had dental caries and that half had never been to the dentist. It is paramount to both the school district and the School of Dental Medicine that this valued program be sustained.
In the 2003–04 school year, Healthy Smiles visited eighty-three schools (the program had hoped to have visited all 101 schools in the CMSD), delivered oral health education to more than 10,000 children, treated 4,500 children and placed more than 12,000 sealants (each second grader potentially has four molars and each sixth grader, eight molars, to seal), and referred 2,300 children to the dental network for additional care. That network has grown to include sixty dental offices with more than eighty dental practitioners, as well as the three safety-net clinics previously mentioned. Those sixty offices admittedly are only a small proportion of the total number of dental offices in the Greater Cleveland area. The early clinical experience provided by Healthy Smiles has been well received by current and future dental students. A recent survey of Case dental students identified the early clinical experience provided by Healthy Smiles as one of two top reasons that students chose Case over other dental schools (the other reason being the school’s use of technology). Because Case dental students are sensitized to the needs of underserved children, we believe that as graduates they will be more cognizant of access-to-care issues when they enter private practice. As our fourth-year students graduate in 2005, and we do a longer-term evaluation of Healthy Smiles as a whole, we can test this hypothesis. Because some 70 percent of the children seen through the program are low-income African Americans, the program is helping to reduce disparities in Cleveland.
The two components that have largely driven Healthy Smiles forward are the sustained funding and the fundamental change in the dental school’s curriculum and clinical practice. The Saint Luke’s Foundation became more than just the funder—it became a partner when it elevated Healthy Smiles to a strategic initiative. This commitment of sustained funding has helped tremendously in attracting additional funding both locally and nationally. Through its investment in Healthy Smiles, Saint Luke’s has realized a high impact on health services and health education in the community that it serves. Data and information gathered by Healthy Smiles may also be useful in implementing health policy changes, which is of interest to the foundation. The dental faculty’s commitment to providing contemporary programs in oral health education, patient care, research, scholarship, and service has been essential to the success of this program and has placed the school at the top of its peer institutions. The results of a 2002 survey of fifty-six U.S. dental schools, conducted by the Case School of Dental Medicine, indicated that Case requires first-year dental students to complete more clinical requirements than any other dental school. Case first-year students are required to take a seventy-two-hour preparatory didactic/laboratory course and complete more than 100 hours of clinical experience performing preventive treatment in the form of sealants. Of the dental schools surveyed, two-thirds have no clinical experience required for first-year dental students, and one-third require less than ten hours.15 This early clinical experience provides our students the opportunity to develop academic knowledge and clinical skills simultaneously, helping them understand and retain the overall relationship of concepts taught. The Healthy Smiles program has fostered a unique partnership between the university’s School of Dental Medicine, a local health care foundation, and the public school district. It also has given Cleveland’s children access to desperately needed oral health care. All in all, the program provides a unique learning opportunity for dental students, while exposing them to the oral health needs of underserved children.
Jim Lalumandier (james.lalumandier{at}case.edu), who is board certified in dental public health, directs the Healthy Smiles Sealant Program. Also, he chairs the Department of Community Dentistry at Case Western Reserve University’s School of Dental Medicine, in Cleveland, Ohio. Kay Molkentin is the former director of program development, Office of Corporate and Foundation Relations, at Case Western Reserve University. We acknowledge our funders and partners, especially the Saint Luke’s Foundation of Cleveland, Ohio, which made our vision a reality.
| |||||||||||||||||||||||||||||||||||
Top
Establishing outreach.
The pilot phase.
