Review of proposed oral health workforce models: Part I.

ADHP? DHAT? CDHC? OPA? POHT? These strange acronyms all have one thing in common. Each of them represents a new or existing model for the dental workforce that is specifically designed to address the needs of those Americans who lack access to even the most basic dental care. This article and the second part to following in the next issue of Access are provided as a guide to these models and what they might mean to the future of practicing dental hygienists and the entire dental hygiene profession in this nation (see comparison table on pages 22 and 23).

To thoroughly grasp how all of these models were developed, it is important to begin at the beginning ... with the causes for the need for the models in the first place. In a landmark report issued in 2001, entitled Oral Health in America: A Report of the Surgeon General, U.S. Surgeon General David Satcher, MD, concluded that the public infrastructure for oral health is not sufficient to meet the needs of disadvantaged groups and is disproportionately available depending upon certain racial, ethnic and socioeconomic factors within the U.S. population. (1) In other words, according to the Surgeon General's report and other studies, if you live in the U.S. and happen to be poor, Native American, Hispanic or a non-Hispanic black, you have a far greater chance of suffering from untreated dental caries than most non-Hispanic whites. (2)

The access to care problem is further compounded by forecasts that predict a growing shortage of dentists to treat those in need. In a 2006 article entitled "Recruitment and Retention of a Quality Workforce in Rural Areas," the National Rural Health Association found that an estimated 6,000 dentists retire annually, while only 4,000 dental school graduates enter the workforce each year. (3) Further, these workforce realities come at a time when, according to the Health Resources and Services Administration (HRSA), an estimated 108 million Americans lack dental insurance and over 2,000 Dental Health Professional Shortage Areas (DHPSAs) have been identified by the administration. (1)

Still another (and some would argue the most important) piece of the access to care puzzle is the financial resources necessary to bring those who need treatment into the oral health care system. Medicaid is the only public program currently available that provides a guarantee of access to dental care for those economically disadvantaged patients who qualify. In addition, for those with incomes too high to qualify for Medicaid, the State Children's Health Insurance Program (SCHIP), which was enacted in 1997, offers expanded oral health care, but the benefit is not currently defined and dental health coverage remains optional under the program. Interestingly, in fall 2007, a large coalition of dental associations including the American Dental Association (ADA) and the American Dental Hygienists' Association (ADHA) came together to lobby Congress for a reauthorization of the SCHIP program that included $35 million set aside for oral health. Though the legislation did not gain approval during last fall's session, proponents including ADA and ADHA expect to continue their support when a replacement bill is introduced in the upcoming session.

These funding limitations on access to care for low-income patients are compounded by the relatively low numbers of dental practices set up to treat these patients. According to some reports, reimbursement rates for dentists are currently one-half to one-third the rate of fees that dentists see in private practice. (4) Other studies have documented instances that show as few as 30 percent of licensed dentists in a state allow more than 10 percent of their patients to be Medicaid enrollees, and only one of six dentists who participate in the program receives $10,000 or more in Medicaid payments per year. Reasons for the low dentist participation rate include program-related issues such as complicated paperwork, slow reimbursement and payment delays often due to paperwork issues and claims denials, as well as patient-related issues such as the perception that Medicaid-enrolled patients break appointments more frequently than others and are less compliant with treatment recommendations. (5)

All of these factors contributed to a troubled oral health care system that was thrust onto the national stage in 2007 with the untimely death of a 12-year-old Maryland boy. The Washington Post, on Wednesday, February 28, 2007, reported that Deamonte Driver had died of complications resulting from an untreated dental abscess after bacteria from the untreated tooth had spread to his brain. According to the article, problems with the Medicaid oral health program and lack of access to a dentist were largely to blame for the boy's fate. (6)

These issues have driven a variety of organizations and individuals to pioneer new dental workforce models specifically designed to address the access to care issue. We will now take a look at several of those models and hear comments from some of their proponents.

The Advanced Dental Hygiene Practitioner

In an effort to address the severe oral health disparities plaguing millions across the United States, the American Dental Hygienists' Association adopted three key resolutions at its 81st annual session held in 2004, which will impact the oral health of the public. Among these resolutions was a call for the creation of an Advanced Dental Hygiene Practitioner (ADHP) position.

ADHA has created the ADHP as a mid-level oral health care provider that will leverage the existing dental hygiene workforce to have an even greater impact on the delivery of care to those in need.

Mid-level health care providers have proven effective and successful in a number of medical fields. As a mid-level oral health provider, the ADHP will serve in a capacity similar to that of the nurse practitioner in medicine. The ADHP will add a new member to the oral health care team and provide an additional point of entry into the oral health care system for those currently disenfranchised by the system.

A recent survey conducted by the National Association of Community Health Centers found that restorative and preventive services were the top two needed oral health services as identified by the Federally Qualified Health Centers (FQHCs) surveyed. (7) The report also noted that among non-physicians, dentists have the highest rate of provider vacancies in FQHCs.

ADHPs will be educated and licensed to provide both preventive and limited restorative services to meet identified patient needs. ADHPs will bring an increasing numbers of patients into the oral health care pipeline and make necessary referrals to dentists and other medical professionals, serving to strengthen the crucial link between the oral health, medical and community networks.

The concept of mid-level providers in oral health is not new. Currently, more than 40 countries, including Canada, New Zealand, Australia and the United Kingdom, allow mid-level practitioners to practice in oral health. (8)

As envisioned, the ADHP will be a licensed dental hygienist educated at the master's degree level, the general academic standard for mid-level providers. In addition to the full range of dental hygiene clinical services, ADHPs will administer minimally invasive restorative services and will also have prescriptive authority. ADHPs will be educated in health promotion and disease prevention, provision of primary care, case and practice management, quality assurance and ethics, which will provide a comprehensive approach to the delivery of oral health care services.

ADHPs will provide care in a variety of public health settings--schools, clinics, and long-term care facilities among others-to a diverse patient population. The ADHP model is a meaningful and substantive response to the call of the U.S. Surgeon General to increase access to oral health care services for the nation's underserved. (8)

When interviewed, 2007-08 ADHA President Jean Connor, RDH, spoke to the inherent strengths of the ADHP model.

"The projected growth in the dental hygiene workforce, for which the U.S. Bureau of Labor Statistics forecasts 40 percent growth by 2015, will provide an ample workforce to meet the needs of populations lacking access to care," said Connor. "The ADHP model as designed provides the public with a licensed provider who has received an accredited education to the master's degree level. Further, this model is based upon the nurse practitioner concept, which has been highly successful in medicine. The public, regulators and legislators are all familiar and comfortable with this type of model, which will prove invaluable in bringing patients who lack care into the oral health care system and creating the legislation necessary to implement the model."

Connor continued to explain that aside from the ADHP, there are already other ways that dental hygiene can contribute to alleviating the growing access problem.

"First, I want to reiterate ADHA's support of SCHIP and Medicaid reimbursement reform," said Connor. "Both of these programs are important pieces in solving the crisis, but by themselves do not provide a total solution."

"Second, if we were to consider a more uniform scope of practice for dental hygiene across the country, then dental hygienists practicing right now could begin to make a difference by being allowed to practice up to the level of their education," said Connor. "One example would be programs that allow dental hygienists to apply sealants for school children under general supervision with collaborative practice agreements that are already in place in many states. This is just one relatively easy way that dental hygienists could make a difference in the access problem in the near term."

Current ADHP Status

In March 2008, at its winter meeting, the ADHA Board of Trustees adopted the Competencies for the Advanced Dental Hygiene Practitioner. Concurrently, the first ADHP educational program was planned by the Minnesota State Colleges and Universities system using the approved ADHP competencies, and the first ADHP legislation was introduced in the Minnesota state legislature. Look for an article describing lessons learned from the Minnesota experience in an upcoming issue of Access.

The Community Dental Health Coordinator and Oral Preventive Assistant

In 2006, in answer to the call to create new allied dental health care positions to address the access to care crisis, the ADA House of Delegates accepted the report of the Workforce Task Force and established the Workforce Models National Coordinating and Development Committee (NCDC) to create two new positions to address the needs of the underserved. (9) The results were the Community Dental Health Coordinator (CDHC) and the Oral Preventive Assistant (OPA).

According to ADA, the vision for the OPA program proposes an additional capability set for the dental assistant that is focused on the basics of preventive care--including oral hygiene education, the application of fluorides, placement of sealants, and coronal polishing for all patients--along with the ability to perform scaling procedures for periodontal Type I (gingivitis) patients. The view is that this member of the team would provide services that are supplemental to those provided by the dentist or the dental hygienist, freeing up their time to provide the more advanced level of services in keeping with their level of education and training. The OPA will work primarily in private dental offices under dentist supervision and enable the dental team to provide care at the appropriate levels of training--potentially reducing the costs of treatment and increasing access to care.

Initially, the NCDC envisioned the OPA as a new type of provider requiring 12 months of training. After further investigation comparing curriculums for the proposed OPA capabilities to competencies required for Commission on Dental Accreditation-accredited dental assisting education programs, the committee believed the OPA program should be developed to build on existing CODA-accredited dental assisting programs. (10)

According to ADA literature, the other new provider proposed by ADA, the CDHC, will be responsible for promoting oral health through organized and dentally coordinated community-based promotion and prevention programs. As a member of the dental team led by a dentist, the CDHC will work in underserved communities where residents have no or limited access to dental care. They will influence local health and community organizations to adopt initiatives to promote oral health.

The CDHC will be new mid-level allied dental personnel employed by FQHCs, the Indian Health Service and tribal clinics, state or county public health clinics, or private practitioners serving the dentally underserved areas. As a member of the dental team, the CDHC will enable the existing dental workforce to expand its reach deep into underserved communities and influence local health and community organizations to adopt initiatives to promote oral health.

Aside from working in health and community settings, the CDHC will collect information to assist the dentist in the triage of patients and address the social, environmental and health literacy issues facing the community population. Another important role of the CDHC will be educating community members on preventive oral health care and assisting them in developing goals to promote and manage their own personal oral health. Linking patients to avenues of oral health care will also be an important role for the CDHC in working with underserved populations going through the maze of the health and dental care systems. (11)

The educational curriculum for this program is currently in development, but according to ADA literature, the program will be approximately 18 months in length and include a comprehensive curriculum with objectives, outlines, teaching aides, resources, learning activities and evaluation mechanisms. In preparing for this story, Access learned from ADA President Mark Feldman, DMD, that the full CDHC educational competencies will be available in the fall of 2008 for presentation to the ADA House of Delegates.

Current CDHC/OPA Status

Following the development of the curriculum, phase two of the program calls for the CDHC training program model to be piloted in urban, rural and Native American reservations.

The pilot training program sites that have been selected are:

* Urban--Michigan Coalition for Development and Implementation of the Community Dental Health Coordinators, in collaboration with the Wayne County Community College District. Pending state approval, this training will occur in FQHCs.

* Rural--University of Oklahoma, with Rio Salado College (Arizona) delivering the online components of the curriculum. The hands-on clinical training will occur in Indian Health Service facilities. Pending final approval by the Oklahoma Dental Board, it will also occur in FQHCs.

* Native American--The University of California, Los Angeles and Salish Kootenai College, with Rio Salado College (Arizona) delivering the online components of the curriculum. The hands-on clinical training will occur in Indian Health Service facilities in several different states. (12)

Feldman spoke to Access for this article on the need for and the strengths of these workforce models.

"I just want to say, first, that I think it's important to stress that in my opinion, it's dangerous to go into the public policy arena and just start talking about mid-level providers because there is no level of understanding about what a mid-level provider actually means," said Feldman. "This could cause the policymaker to base decisions just on the bottom line of what is going to cost the least, and what they really need to do is provide increased Medicaid and SCHIP funding to allow patients to get the care they need."

Feldman also confirmed that ADA remains committed to continue working with coalitions of dental and medical organizations, including ADHA, to secure Medicaid reimbursement reform and SCHIP reauthorization containing a dental provision.

"We all have a stake in this," said Feldman.

When asked about the models, Feldman said, "The CDHC and the OPA really have their genesis in the fact that there is no way that there is ever going to be enough manpower to treat all the caries that is out there in this nation, so you have to concentrate on prevention."

"The main difference in these models is of course is that they are under the general supervision of a dentist, and those procedures that should be done by a dentist will be done by a dentist. One of the strengths of this model is that the vision for the CDHC is that the position will work in communities where people have limited or no access to dental care, and we envision people who will fill these positions actually coming from the communities that they serve, which will overcome cultural and language barriers to care," said Feldman. "The OPA, by contrast, will perform a similar function bringing patients into the dental care system, but they are more likely to work within the dental offices as well as some work in schools and health centers."

References

(1.) U.S. Department of Health and Human Services. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

(2.) U.S. Department of Health and Human Services. The professional practice environment of dental hygienists in the fifty states and the District of Columbia, 2001. Washington, DC: Health Resources and Services Administration, National Center for Workforce Analysis Bureau of Health Professions, April 2004.

(3.) Recruitment and retention of a quality workforce in rural areas. National Rural Health Association, November 2006.

(4.) Moskowitz MC. State actions and the health workforce crisis. Washington, DC: Association of Academic Health Centers, 2007.

(5.) Hughes, Dimiano, Kanellis et al. Dentists' participation and children's use of services in the Indiana dental Medicaid program and SCHIP. J Am Dent Assoc 2005; 136 (4): 517-23.

(6.) Otto. For want of a dentist. Washington Post, February 28, 2007:B01.

(7.) Heath centers' role in addressing the oral health needs of the medically underserved. National Association of Community Health Centers, August 2007.

(8.) American Dental Hygienists' Association. Advanced dental hygiene practitioner fact sheet. January 2008. Available at www.adha.org/downloads/ADHP_ Fact_Sheet.pdf. Accessed May 2008.

(9.) Fox. ADA creates new options for the dental team. Available at www.ada.org/ prof/resources/pubs/adanews/printarticle.asp?articleid=2231. Accessed May 2008.

(10.) Fox. New workforce proposal, oral preventive assistant curriculum planned. April 2008. Available at www.ada.org/prof/resources/pubs/adanews/printarticle.asp?articleid=2985., Accessed May 2008.

(11.) Dental team careers: community dental health coordinator. Available at www.ada.org/public/careers/team/cdhc.asp. Accessed May 2008.

Look for part two of this article in the next issue of Access.

Oral Health Care Workforce--Current and Proposed Providers

                  Advanced Dental Hygiene    Oral Health
                   Practitioner (ADHA)       Practitioner (OHP)

Developed by      American Dental            Compromise reached by
                  Hygienists' Association    Minnesota lawmakers,
                                             Minnesota Dental
                                             Hygienists' Association,
                                             Minnesota Dental
                                             Association, Safety Net
                                             Coalition, University of
                                             Minnesota School of
                                             Dentistry, Minnesota
                                             System Colleges and
                                             Universities

Stage of          Competencies approved      ICI In 2008, the OHP was
Development       March 2008 First ADHP      established in Minnesota
                  master's program slated    state statute. A workgroup
                  to begin at Metropolitan   will convene in mid 2008
                  State University in St.    to make recommendations
                  Paul, Minn., in mid        about education and
                  2009.                      licensure requirements for
                                             the OHP. Recommendations
                                             are due by Dec. 15, 2008.

Certification     Credentialed and state-    Credentialed and state
License           licensed                   licensed

Education         18-24 months at the        To be determined by the
/Training         master's-degree  level     workgroup; graduate of an
                                             accredited program

Proposed          Advanced preventive        Advanced preventive
Preventive        therapies in addition to   therapies in addition to
Scope             existing dental hygiene    existing dental hygiene
                  duties                     duties

Proposed          Uncomplicated              Uncomplicated extractions,
restorative       extractions, temporary     temporary restorations,
scope             restorations, palliative   palliative temporization
                  temporization

Other relevant    Case coordination,         Primary diagnostic,
scope             triage, limited            limited prescriptive
                  prescriptive authority,    authority
                  policy development/
                  advocacy, translational
                  research, business/
                  practice management

Proposed          Public health settings,    Public health settings
settings          community health           and community centers
                  centers, possibly
                  private practice

Proposed          Collaborative              Collaborative management
supervision       relationship with          agreement with a dentist,
                  dentists and other         to be defined by workgroup
                  health care providers
                  envisioned with strong
                  referral networks

Other relevant    * 13-member advisory       * Similar to Advanced
information         committee of various       Dental Hygiene
                    oral health                Practitioner
                    organizations.           * 13-member workgroup,
                  * Congressional report       majority dentists
                    language enacted in FY   * Oral Health
                    2006 encouraged HRSA       Practitioners are not
                    testing the concept.       authorized to practice
                  * ADHA seeking               prior to January 1, 2011.
                    demonstration project
                    for ADHP concept.

                  Oral Preventive            Community Dental Health
                  Assistant (ADA)            Coordinator (ADA)

Developed by      American Dental            American Dental
                  Association                Association

Stage of          Curriculum not yet         Curriculum completed,
Development       released                   but not yet released

Certification     No license required,       No license required, as
License           as proposed.               proposed

Education         3 months in addition       12-18 months
/Training         to dental assisting
                  program

Proposed          Oral hygiene               Sealants, polishing,
Preventive        instruction, scaling       scaling (type I perio),
Scope             (type I perio),            collection of diagnostic
                  polishing, sealants        data for DDS

Proposed          N/A                        Palliative temporization
restorative                                  (with hand
scope                                        instrumentation only)

Other relevant    Collection of              Development of community-
scope             diagnostic data and        based oral health
                  disease prevention         programs
                  education.

Proposed          Primarily in private       Community-based settings;
settings          dental office, possibly    public health; possible
                  in community-based         private practice
                  settings.

Proposed          Two levels: Direct--       Two levels: Direct--
supervision       patient care would         patient care would
                  be directly supervised;    be directly supervised;
                  General--education         General--community-based
                  duties.

Other relevant    * Marketed as a career     * ADA announced plans in
information       "entry point" position.    March, 2005 to pilot the
                                             CDHC in OK, MI, and MT.

                  Dental Health Aide Therapists
                  in Alaska

Developed by      The model was developed in New
                  Zealand, although over 40 other
                  countries have some form of dental
                  nurse or therapist. The Indian Health
                  Service in Alaska employs DHATs in
                  remote regions.

Stage of          8 trained and practicing in IHS Alaskan
Development       villages; 4 more close to completion in
                  the program

Certification     Certified by local IHS board
License

Education         2-year program in New Zealand
/Training         Clinical rotation in Alaska as part of U. of
                  Washington MEDEX program

Proposed          Oral health education, fluoride, sealants,
Preventive        polishing, scaling
Scope

Proposed          Fillings, uncomplicated extractions
restorative
scope

Other relevant    Local anesthesia
scope

Proposed          Remote Alaskan villages, some
settings          accessible only by plane or dogsled

Proposed          General supervision, standing orders,
supervision       DDS reviews electronically

Other relevant    * No legislative/regulatory activity is
information       pending to bring the DHAT to the lower
                  48 states and Hawaii to practice.