Problem Addressed

• High rates of occurrence: Tooth decay remains one of the most common childhood conditions; it is five times more common than asthma and seven times more common than hay fever. More than half of children ages 5 to 9 have had at least one cavity, while 78 percent of all 17-year-olds have experienced tooth decay.¹
• More prevalent among low-income and uninsured children: Children and adolescents living in poverty suffer twice as much tooth decay as other children, and their cavities are more likely to go untreated. Uninsured children are 2.5 times less likely to receive dental care than children from families with medical insurance.¹ Although more than 20 million children receive health coverage through Medicaid,² many lack adequate access to dental care. Recent estimates suggest that up to two-thirds of children with public health coverage had not visited a dentist in the past year.³
• Limited access for children with disabilities: Oral health care is the most prevalent unmet health need among U.S. children with medical, physical, or developmental disabilities, with many dentists lacking the knowledge and resources necessary to serve this population. A study found that fewer than 1 in 10 general dentists regularly provide care to children with disabilities.⁴

Description of the Innovative Activity

• Shared leadership and responsibility: The clinic operates as a partnership between Carilion Clinic and Roanoke's Community Based Health Care Coalition (see the Context section for more information on these organizations). Carilion Clinic provides rent-free space at Carilion Roanoke Community Hospital, along with all necessary infrastructure, such as utilities, housekeeping, maintenance, and human resources. Carilion Clinic also assumes primary responsibility for operating the pediatric dental program, while the coalition provides ongoing policy guidance, using the frontline knowledge and expertise of member agencies to advise on how the clinic can best meet community needs.
• Target population: Carilion Clinic Dental Care–Pediatrics offers dental care to children and adolescents (from birth to age 20) who are uninsured or enrolled in Medicaid or Family Access to Medical Insurance Security, Virginia's insurance program for children living in poverty who are not eligible for Medicaid. The clinic also serves children and adolescents who are medically, physically, or developmentally disabled, regardless of insurance status or family income.
• Fee structure and assistance: Although services are not offered free of charge, the clinic established a fee schedule in which costs are set at a lower rate than at 50 percent of other area dental offices. The vast majority of patients are covered by Medicaid or Family Access to Medical Insurance Security. Those few self-pay patients who are not eligible for public insurance and cannot afford to pay for care often have their fees absorbed by the hospital.
• Full-service dental care clinic: The clinic is open Monday through Friday from 8 a.m. to 4:30 p.m., with a dentist on call at night and on weekends. Equipped with state-of-the-art tools such as pediatric dental chairs and customized instruments for small mouths, clinic staff perform a full array of dental procedures and diagnostic services, including routine checkups and cleanings, x-rays, fluoride treatments, tooth extractions, mirror and explorer examinations, sealants, tooth restoration, and treatment of craniofacial deformities.
• Limited orthodontic care: Although the clinic's capacity for orthodontic procedures is limited, one part-time orthodontist provides corrective treatment for malocclusion, space maintenance and interceptive orthodontics, and other procedures.
• Services catered to children with disabilities: The clinic strives to provide services that meet the special needs of medically complex and developmentally delayed children and adolescents. Clinic facilities are designed to allow access by wheelchairs or gurneys to x-ray and treatment rooms. Dentists and staff are trained in using a wide array of techniques to help developmentally disabled patients feel calm and comfortable, including in-office procedural sedation or general anesthesia for those who need it. Music and cartoons are available in examination rooms, and dental staff take extra time during appointments to establish a rapport with disabled patients and their caregivers, identifying any unique needs they might have and finding ways to make the visit go smoothly.
• Followup to reduce no-shows: Because patients from the clinic's target population tend to have a higher "no-show" rate than those treated in a traditional dental practice, clinic staff make a special effort to encourage patients to make and keep appointments. For example, appointments are scheduled no more than 1 month in advance, and staff place reminder phone calls and send reminder cards in the mail to patients with upcoming visits.

References/Related Articles

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Innovator Disclosures

Results

• Increased access to dental care: A survey of more than 600 parents and guardians of clinic patients conducted between July 2002 and June 2003 found that 95.5 percent reported that the clinic had increased access to dental care for their children. A similar survey of 462 parents and guardians conducted the following year found that this figure jumped to 97.2 percent.
• Improved oral health: An unpublished 2003 study examining 20 randomly selected clinic patients who had completed at least two follow up visits found a statistically significant improvement in oral health (as measured by counting decayed, missing, and filled teeth) after they received treatment at the clinic. The study was reviewed and found valid by the Virginia Department of Health. A second validation study of 100 similar patients found a 74.3-percent reduction in tooth decay.
• Anecdotal reports of fewer toothaches: Roanoke area school nurses report that absences due to dental pain dropped significantly following the opening of the clinic. In addition, doctors, nurses, and administrators from hospital EDs report fewer children presenting with a primary diagnosis of tooth pain since the opening of the clinic, even as tooth pain remains one of the most significant problems for adult patients.
• Highly satisfied physicians: ED physicians report high levels of satisfaction with the ability to refer uninsured pediatric patients to the clinic; prior options for referrals were extremely limited.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Seeking funding: To get the clinic up and running, Carilion staff sought and received approximately $500,000 in grant funding, of which $260,000 went toward facility renovation and purchase of capital equipment. Several of these grants were multiyear pledges of support.
• Establishing roles: Realizing that Carilion Clinic could absorb many of the overhead costs associated with running the pediatric dental care program, Carilion administrators volunteered to take the lead in managing day-to-day operations. Community Based Health Care Coalition member agencies agreed to serve as ongoing advisers to the project, providing guidance on issues such as publicity, patient eligibility, and scheduling/"no-show" policies.
• Hiring staff: Carilion initially hired two pediatric dentists and a team of support staff. Although most of the dental clinic's staff was comprised of new hires, a few existing Carilion Clinic employees were reassigned to positions at the dental clinic.
• Building patient volume to increase reimbursement: To reduce the clinic's dependence on grant funding, the program enacted a plan to boost patient volume, thereby increasing the amount of Medicaid reimbursement and other revenues. As a part of this effort, the clinic provided pediatric dentists with monetary incentives to encourage productivity. During the first 4 years of operation, the clinic was able to boost revenues to the point that they covered the majority of direct expenses.

Resources Used and Skills Needed

• Staffing: One of the clinic's two original pediatric dentists left the practice in 2008. The clinic currently employs 2 pediatric dentists, 1 part-time orthodontist, 1 part-time dental hygienist, and a support staff of 10 individuals. Recruitment is ongoing for an experienced general dentist whose particular focus would be adolescents and teens. All staff are considered employees of Carilion Clinic.
• Costs: Operating expenses for the clinic in 2009 were $788,291, with a per-visit cost of $137.05. Clinic expenses are covered by clinic revenues, so the clinic is not seeking new sources of funding.

Funding Sources

Getting Started with This Innovation

• Seek expert advice and information: To generate ideas and gain support, tour other successful clinic sites, talking to their leaders and establishing lines of communication with staff who work on similar projects.
• Enlist a network of community stakeholders: To establish the issue as a community priority, assemble a coalition of area schools, churches, and service agencies to work together on increasing access to pediatric dental care. This step also invites time and attention from foundation leaders and legislators who may be interested in funding or advocating for the program's services.
• Partner with a larger institution: Support from and collaboration with a major hospital or health system can help reduce otherwise significant operating expenses, including physical space, utilities, equipment, and human resources.
• Establish a dedicated leader: To increase continuity and prevent confusion among stakeholders, allot one full-time staff member to be responsible for coordinating efforts, particularly during the initial stages of fundraising.

Sustaining This Innovation

• Advocate for adequate reimbursement rates: Because professional fee revenues are vital to sustaining this type of program, lobby state legislators to increase reimbursement rates for Medicaid and other statewide insurance programs.
• Consider use of provider incentives: Incentives can encourage dentists to see high volumes of patients, thereby compensating for low Medicaid reimbursement.
• Keep staff motivated: Boost staff morale by periodically reminding them of the help they are providing to children in need, and offer "pep talks" or other motivational programs as needed.

Additional Considerations and Lessons

• This dental clinic model involves sponsorship by a hospital, but a civic or fraternal organization could serve as sponsor. The high initial cost of starting a dental clinic makes it difficult to locate sponsors. The urgent need in nearly all communities makes it relatively easy to obtain grant funding to cover initial expenses, but coordination and timing considerations can be complicated.

Use By Other Organizations

• Children's Hospital of Richmond, VA has adopted this hospital-based clinic model after consulting with Carilion Clinic Dental Care-Pediatrics. In addition, representatives of approximately 30 community groups have communicated with clinic leaders for advice on establishing a safety net dental clinic. Many communities in Virginia are adopting a modified version of this clinic model, establishing dental clinics that are co-located and associated with a free clinic.