Where are we headed? Redefining Dental Hygiene Education and Practice.
Dental hygienists are integrated into the health care delivery system as essential primary care providers to expand access to oral health care.
This envisioned future will require an understanding of the contextual drivers for change, examination of the core competencies for dental hygienists that exist and that will need to be added, and identification and management of the facilitators and barriers to transformation. These issues were the subject of a panel at the September 2013 symposium, Transforming Dental Hygiene Education, co-sponsored by the American Dental Hygienists' Association (ADHA), the Santa Fe Group and the ADHA Institute for Oral Health. The panel, "To Where We Are Headed: Guiding the Redefinition of Dental Hygienists' Education and Practice," examined the transformation of dental hygiene education from the perspectives of the federal government, academic administration, research and organized dental hygiene.
Marcia Brand, PhD, BSDH, MSDH, deputy administrator, Health Resources and Services Administration provided the federal perspective. The contextual drivers she recognized included the Patient Protection and Affordable Care Act, which stands to have a downstream impact on demand for oral health services; increasing emphasis on collaboration among health care providers; and a consensus among stakeholders around the triple aim described by Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services, which is to deliver health care that:
* Improves the individual patient experience of care
* Improves the health of populations and
* Reduces the per-capita costs of care for populations.
Brand also recognized among the contextual drivers for transformation what she termed the "co-occurring oral health movement," wherein advocacy is for people, not professions, and oral health is being integrated into health care. An example is the establishment of "innovation centers" by the Centers for Medicare and Medicaid Services--demonstration projects to explore the effectiveness of new health care providers and delivery systems.
In terms of competencies. Brand said she sees a need to create a provider for a setting. The federal perspective looks at payors, cost, quality and access, seeking to provide the best care for the lowest cost. She cited the concept of "zero-basing" the health disciplines--identifying basic skills to provide the best, most cost-effective services in the settings where oral health care is delivered. Acknowledging that there is no such thing as a truly two-year dental hygiene degree, she expressed concern over "degree creep," wherein the entry level to practice rises over time. Among the consequences of degree creep is hampering of diversity. As an alternative, Brand said that she advocates evidence-based credentialmg, and asked "Where is the evidence that the length of time spent in school ensures competency?"
Facilitators to change, Brand said, include openness to innovation--new practice patterns and providers, integration of care and harnessing public demand. Barriers she identified were professional isolation, lack of dental hygienists in policy-making roles and a dearth of policy makers with a full understanding of access to care issues. She asked educators to encourage students to intern in government: "We need folks who can speak the language," she said.
Pamela Zarkowski, JD, MPH, BSDH, provost and vice president, Academic Affairs, University of Detroit Mercy, provided the educational and administration perspective. As for contextual drivers, she recognized the need to advocate for transformation in such a way as to convince multiple audiences. Students themselves have diverse backgrounds and concerns, including whether or not they will find work upon graduation. Faculty have a different set of questions and the academic administration more still. What, she asked, motivates academic programs to change?
In terms of new competencies, she noted the need to consider more than Just the new clinicians. The need to educate interprofessionally will require additional course-work for faculty. Existing practitioners who want to acquire new skills may seek solutions in continuing education and reentry into advanced education programs. She recognized that the terms "personalized, predictive, preventive, participatory" of the P4 medicine concept could also serve as a starting point for thinking about competencies that are informed by patient need.
Zarkowski's facilitators for transformation included professions and professionals within and outside dental hygiene and dentistry, including educational and institutional colleagues as well as legislators and administrative boards. She also identified communities with the three characteristics of purpose, need and power as facilitating change.
Barriers that Zarkowski cited were lack of vision and commitment on the part of the dental hygiene education and practice community, fear of change and risk, the inability to gain support from colleagues and academic institutions, and the difficulties associated with licensure and certification for a transformed profession.
Harold Slavkin, DDS, professor, Ostrow School of Dentistry, University of Southern California, provided the research perspective. Among the contextual drivers he saw were that people are living longer lives with the concomitant expectation of better lives. For dental hygienists, he said, there is an opportunity to play a part in the management of chronic conditions that older adults face. New technology on the horizon will bring nonmechamcal biofilm removal; guided tissue remineralization; and increased use of personalized health care, including salivary diagnostics, all of which have a potential role for future oral health practitioners.
Slavkin said that competencies for the future dental hygienist will include an understanding of the inflammatory response, immunity and management of the effects of microbial activity on oral and systemic health. He said that the scientific environment in which health care providers will work will require a profession to be able to represent its own perspective in social, economic and political contexts while integrating expertise with other professions.
Facilitators for transformation that Slavkin identified include the fact that dental hygienists can readily be educated and trained to participate in biomedical and behavioral research. Whether associate, baccalaureate, master's or doctoral, all programs need to contribute to science- or evidence-based health care, and all dental hygienists need to be "sophisticated consumers of science." He encouraged dental hygienists to review the history and evolution of other allied health professions to see how they expanded their scope of practice alongside the formal and informal revision of education and competencies. Federal, state and foundation-driven opportunities, he said, can facilitate transformation of dental hygiene education, research and clinical practice to address gaps and inequalities in societal needs to achieve wellness for all Americans.
State-controlled scope of practice/health care boundaries, and perceptions of other health professions were among the barriers Slavkin identified. "Primary health care for all Americans must include mental, vision and oral health," he said.
Ann Battrell, MSDH, executive director, ADHA, provided a perspective from organized dental hygiene. "If you really want to transform," she said, "that's about moving forward and evolving within a very challenging environment."
In discussing contextual drivers, Battrell acknowledged that a profession must have the infrastructure in place to implement plans and maximize opportunities. Any transformation proposed, she said, must be relevant to the current environment. As an example, she pointed to ADHA's adoption of a definition of advanced practice dental hygiene, which includes provision of diagnostic services.
Battrell sees the dental hygiene diagnosis as the central issue with respect to competencies. "Competencies imply responsibility," she said, adding that dental hygiene diagnosis is part of the Standards for Clinical Dental Hygiene Practice, yet something most dental hygienists have not been able to do, due to restrictive scopes of practice in most states.
Battrell said that this kind of limitation is changing, facilitated by market forces including trends in the delivery of health care and provisions in the ACA. She characterized facilitators for transformation as those forces that have the greatest impact on the public, changing economic factors, and collaboration - between community-based providers, but also between community colleges and universities. Societal demands on state legislatures and state dental boards have increased the number of direct access states, she noted. As legislation moves forward, the educational system will need to keep pace.
As for barriers, Battrell identified lack of integration of the dental team. "Only 23 of 335 dental hygiene programs are located in dental schools," she said. "'Interprofessional education' is a more contemporary topic, but what about intraprofes-sionaP
Information from the Transforming Dental Hygiene Education symposium continues to roll out. Battrell, along with Pam Steinbach, RN, MS, ADHA's director of education and Linda Niessen, DMD, MPH, MPP, president of the Santa Fe Group, will present on the outcomes of the symposium at the March 2014 meeting of the American Dental Education Association.
This edition of Headquarters was prepared by Jean Majeski.
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|Date:||Mar 1, 2014|
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