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Service Delivery Innovation Profile

Comprehensive, Shelter-Based Clinic Enhances Access to Oral Health Services for Homeless in Los Angeles


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Snapshot

Summary

A collaborative partnership between the Ostrow School of Dentistry of University of Southern California, Union Rescue Mission shelter, and other community stakeholders has led to an expansion of services available to homeless individuals in the Skid Row area of Los Angeles. Now, in addition to having access to medical, mental health, and legal services, homeless men, women, and children in central Los Angeles can receive free comprehensive dental services at a safety net dental clinic on site at the Union Rescue Mission shelter. Since 2011, the program has also partnered with a federally qualified health center to offer a seven-chair dental clinic. The clinic has significantly enhanced access to needed oral health services in a population that has no other means of accessing such services. Patients served by the program express a high level of satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on service use, as well as patient and student satisfaction surveys.
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Developing Organizations

Cooperative Health Care for the Homeless Network; Homeless Health Care Los Angeles; Los Angeles County Department of Health Services; Los Angeles Mission Clinic; Los Angeles Unified School District -- 9th Street School; Ostrow School of Dentistry of University of Southern California (USC); Skid Row Homeless Healthcare Initiative; UCLA/Union Rescue Mission Clinic; Union Rescue Mission; Weingart Center/JWCH Clinic
The primary developing organizations were the University of Southern California School of Dentistry and the Union Rescue Mission. Other organizations provided secondary development support.end dobegin pp

Patient Population

Vulnerable Populations > Homeless; Impoverishedend pp

Problem Addressed

There are many homeless and low-income individuals in the Skid Row area of Los Angeles, and these individuals generally lack access to even basic oral health care.
  • Many homeless individuals in need of dental services: According to a street census conducted in 2007, there are estimated to be more than 40,000 homeless people in Los Angeles City on any given day. Approximately 22,000 of these individuals are in the Los Angeles metro area, with 5,000 specifically living in Skid Row, a 52-square block subsection of the inner city representing one of the most densely populated areas of homeless individuals anywhere in the nation. Increasingly, many of these homeless individuals are single women and children under the age of 18.1 Dental caries, gum disease, and tooth loss have been identified as major problems for homeless patients in the shelters and clinics in central Los Angeles.2
  • Few providers: In 2007, the central area of Los Angeles was re-designated a Dental Health Professional Shortage Area for low-income and homeless individuals by the Federal government, receiving one of the highest priority ratings of any area in California. In fact, despite the overwhelming need for oral health care, there was no comprehensive dental clinic available on Skid Row before the opening of the dental clinic at Union Rescue Mission in May 2000.

What They Did

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Description of the Innovative Activity

Through a collaborative partnership with Union Rescue Mission, the University of Southern California (USC) Dental Clinic opened within the Union Rescue Mission shelter to address the oral health needs of underserved populations in the Skid Row area. The clinic offers free comprehensive preventive, restorative, and specialty dental services to uninsured homeless men, women, and children. Key elements of the program include the following:
  • Patient eligibility: The clinic serves men, women, and children who are homeless and lack insurance. Anyone with insurance who comes to the clinic is referred to other appropriate sources of care so that the clinic's ability to act as a safety net provider and serve patients without coverage is maximized.
  • On site, full-service facility: Located onsite at the Union Rescue Mission shelter, the clinic is open 5 days per week between the hours of 7:30 a.m. and 4:00 p.m., and features a laboratory and eight dental units. The dental units consist of specially designed chairs containing all the necessary instruments and equipment to provide comprehensive dental services. Patients receive services provided by licensed dental faculty, dental assistants, and dental students and dental hygiene students who rotate in the clinic for 7-week periods.
  • Free preventative and restorative treatments: The clinic provides free dental exams, diagnoses, x-rays, preventive care (e.g., nutrition, education, hygiene instructions, and prophylaxis), and restorative treatments. Because of the severity and complexity of the dental health needs of the patients, most patients require restorative treatments and often specialty services.
  • Free specialty services: The clinic provides free oral surgery, endodontic treatments, periodontal care, and prosthodontic services (e.g., removable dentures for eligible patients referred from partnering agencies).
  • Community-based outreach, marketing, and screening: Clients learn about available services from a brochure that is distributed in the area, through referrals from service providers in the community and within the shelter system, and through community-based outreach events (e.g., health fairs). The outreach events, which also provide a venue for education and oral screenings, are the result of collaborative activities among community-based organizations in central Los Angeles, including homeless shelters, schools, faith-based organizations, recreational facilities, and health and human service providers. The largest annual event is Project Homeless Connect, a health and social services fair in Skid Row that provides education, screenings, and referrals and coordinates follow up services for hundreds of homeless individuals.
  • Distribution of oral hygiene products: As a supplement to the annual community-based events, the clinic provides oral hygiene products (e.g., toothbrushes and toothpaste) to local homeless service agencies. The University of Southern California School of Dentistry distributes more than 20,000 products annually in collaboration with the Los Angeles Homeless Services Authority's winter shelter program and numerous other agencies.
  • Culturally competent dental student training: The clinic provides didactic instruction to dental students through an introductory orientation session that focuses on dental service delivery to homeless populations and provides background information on cultural diversity. This session is followed by a 7-week supervised rotation at the clinic. The clinic also assigns students problem-based learning cases that incorporate cultural diversity issues, and students may enroll in a Spanish for Dentistry elective course at the school.
  • Interprofessional education: Information provided in February 2013 indicates that the program has added a new component, Inter-Professional Education, to dental student rotations; in this component, students shadow the physician and nurse practitioner students and providers at the UCLA Health Center (adjacent to the Union Rescue Mission) and the master's in social work students and providers at the Pepperdine University Mental Health Clinic (also at Union Rescue Mission).

Context of the Innovation

Union Rescue Mission is a nonprofit organization that provides a comprehensive array of emergency and long-term services to the poor and homeless, including food, shelter, clothing, recovery programs, transitional housing, education, and job training. Through partnerships with local universities, the program also offers medical care, mental health counseling, and legal assistance. Union Rescue Mission operates in an area of Los Angeles County that has received a Health Professions Shortage Area score of 21 (out of 25) for dental services (the highest in Los Angeles County and one of the highest in the state), indicating that it is an area characterized by very high need for dental professionals. An increasing number of requests for dental referrals by Union Rescue Mission residents prompted a shelter-based assessment of acute and chronic oral health services and the identification of available providers in the community to service these needs. After finding a lack of available providers, Union Rescue Mission's leadership began developing a strategy to address the unmet needs of its residents. The program invited the University of Southern California School of Dentistry to collaborate on the building of an on-site dental clinic within the shelter facility, intended to provide essential dental services to augment the continuum of care for this underserved population.

Did It Work?

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Results

Although no formal, comprehensive evaluation has been conducted, post-implementation data related to service utilization, procedures, event participation, and distribution of oral hygiene products suggest that the clinic has significantly enhanced access to needed oral health services in a population that has no other means of accessing such services. In addition, patient and student surveys indicate high levels of satisfaction with services received and training experiences, respectively.
  • Enhanced access to free dental services: In 2008, free treatment services were provided to 1,018 unduplicated homeless individuals who visited the clinic. These individuals had 5,731 different patient encounters and received 19,616 procedures. More than one-third of the encounters were for exams, diagnosis, x-rays, and preventive care, including nutrition, education, hygiene instructions, and comprehensive prophylaxis. The remaining two-thirds of encounters were for restorative treatment, oral surgery, and other specialty care, including endodontic treatments, periodontal care, and prosthodontic services, such as removable partial and complete dentures (more than 500 prosthodontic appliances were fitted, including 212 individuals receiving complete dentures). Information provided in February 2013 indicates that, during 2012, the dental clinic served 1,158 patients (goal: 1,200 over 12 months) and had 6,792 patient encounters (goal: 6,000 over 12 months). Approximately two-thirds of patients were male, and more than 90 percent of patients were over 21 years of age; 53 percent of patients were African American and 29% percent were Latino.
  • High value of dental services provided: Information provided in February 2013 indicates that the fair-market value of dental services and treatment provided by the clinic was $2,198,373 over 12 months, compared with actual fees paid of about $600,000 (the annual clinic budget), which illustrates the good value of funding invested in the clinic. In addition, 422 prosthodontic appliances (180 removable partial dentures and 242 complete upper and lower dentures) were delivered to patients in 2012 at no cost to patients (goal: 400 appliances over 12 months).
  • High patient satisfaction: Four out of five patient comments indicated satisfaction with treatment, although there have been some complaints about waiting times. Patient commentaries often include mention of the health and social benefits of receiving specialty care services, such as improving the ability to chew and enhancing cosmetic appearances and employment prospects. A 2007 clinic survey of 57 patients receiving comprehensive care indicated that 89 percent felt their new smile/teeth made them more employable, and 84 percent believed they were more likely to get a job interview as a result.
  • Enhancing supply of qualified dental providers: The mandatory clinic rotation provides an opportunity for 224 students (144 dental students, 48 dental hygiene students, and 32 advanced standing international students) to learn about culturally competent dental care each year. According to the results of the 2006 University of Southern California School of Dentistry student survey, the vast majority of students reported that the clinic rotation was a "very positive experience." Dental and dental hygiene students frequently commented on their exposure to the positive aspects of service learning, community practice, philanthropy, and professionalism.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on service use, as well as patient and student satisfaction surveys.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Initial meetings between key stakeholders: In partnership, Union Rescue Mission and the University of Southern California School of Dentistry launched a series of meetings to develop a plan for integrating dental services on site. Project leaders invited key stakeholders to participate in these meetings, including representatives from the local department of health services, Skid Row shelters, and clinics serving homeless clients. In addition, development staff from both the shelter and the university helped assess funding requirements, needs, and sources, contacting several major corporations and foundations to request support.
  • Renovation and equipping of clinic space: The University of Southern California provided architectural drawings of the space that would be renovated to accommodate the installation of six dental units, which USC solicited as a donation from a corporate manufacturer. Renovation of space commenced with previously homeless Union Rescue Mission program participants and in-kind support from a construction company, along with support provided by various Union Rescue Mission donors and sponsors. In 1999, all space renovations were completed, and the dental clinic opened in May 2000 with six dental units, a panographic x-ray, a sterilization area, and a laboratory.
  • Federal designation as priority area: In 2002, USC, with guidance from the state planning authority, prepared and submitted an application to the Bureau of Health Professions for designation as a Dental Health Professional Shortage Area, receiving a score of 21 out of 25 for the homeless population in central Los Angeles, meaning that there was a severe shortage of dental professionals available to serve this population. A National Health Service Corps dentist was matched to the site, and this individual has remained, becoming the clinic's director.
  • Ongoing evaluation and expansion: Project leaders conducted ongoing evaluations to monitor service utilization and unmet needs. In response to these evaluations, the clinic added two additional dental units in 2005. 
  • Redesignation as priority area: Despite the expansion, unmet needs continued to grow. In 2007, the area was redesignated with a score of 24 out of 25, the highest priority rating of any area in California. This redesignation not only covered the homeless, but the more general category of low-income populations.
  • Ongoing solicitation for funding: The program continually seeks support for the ongoing provision of oral health services through a collaborative effort to target government program contracts and grants, corporate gifts, foundation grants, service club support, and individual contributions, including from University of Southern California alumni. The clinic submitted an expansion proposal to the Health Resources and Services Administration's (HRSA) Healthcare for the Homeless program in 2008, which was approved and now covers more than one-half of the annual budget. In addition, an "Adopt-a-Chair" campaign is being planned to solicit funding from local foundations, companies, individuals, and school alumni to sustain the clinic. 
  • New partnership opportunity: Information provided in February 2013 indicates that the Ostrow School of Dentistry at USC was invited in 2011 to partner with JWCH Institute to open and operate a seven-chair dental clinic, also in Skid Row; JWCH Institute is a federally qualified health center with no dental services, which resides in a new building across the street from Union Rescue Mission

Resources Used and Skills Needed

  • Staffing: The clinic's staffing configuration includes the clinic director/faculty member, two part-time dental faculty, several volunteer faculty, six dental students, six dental hygiene students, three dental assistants, and a clinic coordinator. The University of Southern California School of Dentistry has established this site as a mandatory clinical rotation for dental and dental hygiene students. To ensure continuity of care for patient return visits, dental students rotate 4 days per week, and dental hygiene students rotate every Friday within a 7-week time period.
  • Costs: Annual operating costs for the clinic in 2008 totaled approximately $600,000, although almost $2,120,000 in patient care was rendered. Many other resources are provided in-kind from Union rescue Mission (e.g., clinic site, including utilities, maintenance, security, and parking) and the university (e.g., quality assurance; malpractice insurance; accounting, payroll, and auditing services; hosting the clinic's administrative office; and partial salary support).
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Funding Sources

Robert Wood Johnson Foundation; Kaiser Permanente; Union Rescue Mission; The Health Resources Services Administration/Bureau of Primary Health Care/HCH through the Northeast Valley Health Corporation; The Unihealth Foundation; Catholic Healthcare West; Change-A-Life Foundation; Individual direct cash contributions; In-kind support; Ongoing solicitations; James Irvine Foundation; California Wellness Foundation; Tom’s of Maine; Henry Schein Company; California Dental Association Foundation; Patterson Corporation; Ostrow School of Dentistry of University of Southern California (USC); Good Hope Medical Foundation; Ralph M. Parsons Foundation; Burbank Dental Laboratory, Inc.
Philanthropic, government, corporate, and individual resources support the project. Startup funding and support came primarily from donors to Union Rescue Mission, while the University of Southern California solicited local corporations to donate equipment. A QueensCare partner grant and Robert Wood Johnson Foundation Local Initiatives Funding Partners grant helped to finance the startup and early operations. The clinic receives ongoing financial support from the Health Care for the Homeless program, which is a part of HRSA's Bureau of Primary Health Care; a successful expansion proposal to HRSA in 2008 increased this support to cover half of the operating expenses. Local foundations sustain much of the present costs, including continuing support from the California Wellness Foundation, Unihealth Foundation, Change-A-Life Foundation, and others. In addition, the California Dental Association and several corporations (Kaiser-Permanente, Tom's of Maine, Henry Schein, and Patterson) have contributed funding. Substantial in-kind support has come from both Union Rescue Mission and the University of Southern California, as detailed above.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Establish a project "champion": Identify and recruit champions for the project within a local health professional school and/or university.
  • Offer balanced and service-oriented training: Ensure that any training, such as the clinical rotation, serves as a positive, service-learning experience, exposing students to the intersection of clinical practice and philanthropy.
  • Identify and partner with key stakeholders: Build relationships with strong and viable community partners who can advocate for the intended target population.
  • Be open to collaborations: Participating faculty, professionals, and students must be willing to participate in collaborative initiatives that go beyond one’s own clinical experience. 

Sustaining This Innovation

  • Be prepared for high costs: Expect the costs of laboratory services and clinical supplies to be quite high because of the complex needs and delayed dental care of the underserved population.
  • Search broadly and continually for funding: Diversify fundraising efforts to support operations, including tapping into the corporate sector and school alumni. Be persistent in fundraising, as financial needs never go away. Providing free care requires an ongoing commitment to networking, partnership forming, and fundraising.
  • Build staff based on the unique needs of the target population: Include culturally and linguistically diverse staff, recognizing that recruiting staff in a Health Professional Shortage Area, particularly one in the heart of Skid Row, can be a challenge (e.g., because of stigma issues) and requires constant attention and focus. Hire with the expectation that the dental problems experienced by homeless populations will be severe and complex and will frequently require long visits. These factors should be considered when forecasting patient volume and service demands. 
  • Utilize priority area designation in staffing: Take advantage of a Health Professional Shortage Area designation to recruit a National Health Service Corps graduate; the present clinic director initially came as such a graduate to fulfill her service obligation. 
  • Try new approaches in addressing missed appointments: Consider "overbooking" and serving urgent care patients as a way to increase staff productivity and time management due to frequent missed appointments among the homeless population. Missed appointments and uncompleted treatments remain an ongoing challenge.
  • Strive for an efficient referral system: Develop a seamless patient referral system to cover both emergencies and the provision of comprehensive care. The clinic's collaborative community partners are still attempting to improve the referral system, including creating equitable eligibility criteria for receiving services and a practical protocol for obtaining medical clearances (e.g., to receive a clinical procedure or to return to work).
  • Establish patient follow up system: Develop a practical system at the onset for tracking and following up on the oral health care of patients (who are transient in nature), which is critical to their personal well-being and the ability to maintain their newly regained oral health.
  • Develop coordinated and comprehensive care: Ensure that dental services are integrated into medical and mental health services for patients, as well as available legal and employment services, in order to help clients improve their overall health and increase their chances of positively changing their lives.

Spreading This Innovation

  • The clinic's model has been presented to local coalitions and at regional and national meetings, including conferences held by HRSA's Healthcare for the Homeless program, the National Oral Health Conference, National Health Service Corps, American Association for Public Health Dentistry, and American Dental Education Association. This level of interest suggests that others are considering it as a model for possible adaptation or replication.
  • The dental clinic's successful operations drew serious interest from another homeless services provider in Los Angeles. As a reflection of the immense and continuing unmet needs, and the success and acceptance of the program's efforts at Union Rescue Mission, the Ostrow School of Dentistry was invited in 2011 to partner with JWCH Institute to open and operate a seven-chair dental clinic, also in Skid Row; JWCH Institute is a federally qualified health center that has provided medical, but not dental, care to homeless clients. The program has worked with JWCH to design, develop, and jointly operate new oral health services at a new site, which opened in the winter of 2011. This new site is an integrated health center, also incorporating public health, mental health and vision care, as well as social services, in a new building, directly across the street from the dental clinic at Union Rescue Mission. The site, named Center for Community Health, reflects a partnership of JWCH (medical), USC (dental), Southern California School of Optometry (vision), with the Los Angeles County Department of Health Services (infectious diseases and mental health services).

More Information

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Contact the Innovator

Niel Nathason, MA, MPH
Assistant Dean, Community Health Programs
Associate Professor, Division of Health Promotion, Disease Prevention & Epidemiology
Office of Community Health Programs
3305B S. Hoover Street, Bldg A-Room A-120
Los Angeles, CA 90089-7001
Phone: (213) 740-1523
Fax: (213) 740-8663
E-mail: nathason@usc.edu

Innovator Disclosures

Mr. Nathason has not indicated whether he has financial interests or business or professional affiliations relevant to the work described in this profile.

References/Related Articles

Union Rescue Mission. University of Southern California Dental Clinic [Web site]. Available at: http://198.61.199.158/services/clinics/#USC.

Footnotes

1 Skid Row Homeless Health Care Initiative. Revised Planning Document for Oral Health Services Integration and Expansion (Phase Three). 2007. Available at: http://www.ccalac.org/files/DOCUMENTLIBRARY/SKIDROW/2008%20Dental%20Plan%20Final%20Document.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 14, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 07, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.