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Service Delivery Innovation Profile

Partnership Between Private Practice Providers and Hospitals Enhances Access to Comprehensive Dental Care for Underserved, Low-Income Pregnant Women


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Snapshot

Summary

The Maternal Oral Health Project provides comprehensive dental care to Medicaid-eligible, low-income pregnant women in Nassau County, NY, enrolled in the State's Prenatal Care Assistance Program. Hospital-based clinics refer women in need of dental services to a periodontist in private practice who has agreed to provide routine dental care to them. These women receive a standard dental check-up and education about oral hygiene, including ways to promote healthy teeth and gums in their children. As necessary, the periodontist provides needed follow-up periodontal care or refers patients to hospital-based dental clinics (for emergency care) or private-practice dentists who have agreed to treat Medicaid patients. The program has enhanced access to routine and followup dental care for more than 2,000 low-income pregnant women, many of whom had significant tooth and/or gum problems that ended up being addressed.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of women receiving routine dental care through the program, and the proportion of these women in need of and receiving followup dental care; data on routine visits came from the periodontist's internal office records, while data on followup care came from a review of the charts of patients seen by the periodontist between April and September of 2008.
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Developing Organizations

Maternal Oral Health Project
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Date First Implemented

2007
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Patient Population

Gender > Female; Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Womenend pp

Problem Addressed

Oral health is a critical part of prenatal care, since pregnant women face an above-average risk of dental problems, and oral infections during pregnancy may be linked to adverse pregnancy outcomes. However, many pregnant women—particularly racial minorities and low-income women—do not get recommended dental care, either because they mistakenly believe they should forgo such care during pregnancy or because they cannot find a dentist willing to treat pregnant women or Medicaid beneficiaries.
  • A critical component of prenatal care: Pregnant women are prone to dental problems because elevated hormone levels cause gums to swell, bleed, and trap food. Up to 30 percent of pregnant women have advanced forms of periodontal disease. Although the evidence is mixed, some studies have linked oral infections during pregnancy to adverse pregnancy outcomes, such as preterm birth and low birth weight.1 In addition, women who visit the dentist during pregnancy can receive valuable education about the importance of oral health for themselves and their soon-to-be-born child, including practical strategies for maintaining good oral health throughout life.
  • Lack of care during pregnancy: Routine dental procedures such as cleanings and cavity fillings reduce the chance of infection and can be done safely during pregnancy. However, many women mistakenly believe they should avoid dental visits during pregnancy, and many dentists remain reluctant to treat pregnant women because they are unaware of current guidelines and/or fear liability issues.2
  • Especially among racial minorities and low-income women: Hispanic and African-American women are less likely to receive routine dental care during pregnancy. For example, one study found that 36 percent of white women got such care during pregnancy, compared with 21 percent of black women and 13 percent of Hispanic women.3 Low-income women face even greater challenges in accessing dental care during pregnancy. In addition to the barriers facing all pregnant women (noted above), they often find it difficult to navigate the health care system and often have a hard time finding a dentist willing to treat them (due to fear of not being reimbursed by Medicaid for treatment).4 In a survey of Medicaid-eligible pregnant women who participated in this program, only 7 percent had received oral health care within the previous 6 months, 42 percent had not seen a dentist in more than 2 years, and 25 percent had not seen a dentist in at least 5 years.

    What They Did

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    Description of the Innovative Activity

    The Maternal Oral Health Project provides comprehensive dental care to low-income pregnant women in Nassau County, NY, enrolled in the State's Prenatal Care Assistance Program (PCAP). Hospital-based PCAP clinics refer women in need of dental services to a periodontist in private practice who has agreed to provide care to Medicaid-eligible pregnant women. These women receive a standard dental check-up and education about oral hygiene, including ways to promote healthy teeth and gums in their children. As necessary, the periodontist provides needed followup periodontal care and/or refers patients to hospital-based dental clinics (for emergency care) or private practice dentists who have agreed to participate. A detailed program description follows:
    • Referral from state-funded clinics: PCAP provides prenatal and obstetric care to Medicaid-eligible pregnant women at hundreds of state-funded clinics across New York. State guidelines require providers at these clinics to refer patients who have an oral health problem or who have not seen a dentist in the past 6 months to a dentist as soon as possible. By arrangement, physicians at three Nassau County hospitals with PCAP clinics (Long Island Jewish Hospital in New Hyde Park, North Shore University Hospital in Manhasset, and South Nassau Communities Hospital in Oceanside) refer clinic patients to a private periodontist in Great Neck who has agreed to provide routine dental care to PCAP enrollees. The faxed referral form grants clearance for routine procedures and medications, and includes a summary of the woman's medical history and obstetric findings.
    • Scheduling appointment and reminders: After receiving a referral, the periodontist's administrative assistant contacts the patient to schedule an appointment at a convenient time. To reduce the risk of missed appointments, she contacts them again the day before and the day of the appointment.
    • Basic dental care and patient education: The participating periodontist and two hygienists (one of whom speaks Spanish) provide standard dental checkups that include examination and cleaning of teeth and gums (including oral cancer screening), limited x-rays (if needed), and diagnosis of any problems requiring additional care. The hygienists also provide in-depth instruction on proper home dental care for adults and children, including brushing and flossing and strategies for preventing cavities in infants and toddlers, such as not sharing utensils and avoiding beverages high in sugar.
    • Followup care: Women with dental problems requiring immediate care, such as active infections, severe pain, or teeth that require extraction, receive a referral to a dental clinic at one of the three participating hospitals. Those whose problems are less urgent receive referrals to private-practice dentists who have agreed to treat PCAP patients. Women who need followup periodontal treatment return to the periodontist for care.
    • Appointment after giving birth: The periodontist's office encourages women to schedule an appointment after giving birth with a participating dentist, so they can get a complete set of x-rays (something that cannot be done safely during pregnancy), recommendations for further treatment, and further guidance related to their children's oral health (including bringing children to the dentist after their first birthday).

     

    Context of the Innovation

    Long Island Jewish Hospital and North Shore University Hospital are both part of the North Shore/Long Island Jewish Health System, and both have hospital-based residency programs with dental clinics. South Nassau Communities Hospital is an independent, community facility. All three sites have PCAP clinics, a state-funded Medicaid service offering complete pregnancy care to expectant women with household incomes at or below 200 percent of the Federal poverty level. Staffed by obstetricians, registered nurses, social workers, nutritionists, and other specialists, these clinics seek to improve pregnancy outcomes in this high-risk population. The three PCAP clinics that participate in the Maternal Oral Health Project serve more than 2,000 patients each year, a large percentage of whom are black or Hispanic.

    The primary impetus for this program came from a periodontist in private practice in Great Neck, NY. Having earned a master's degree in public health, this individual became aware of recent research demonstrating the importance of oral health care during pregnancy, including the possible link between oral health and pregnancy outcomes. He also knew that most underserved women do not receive dental care during pregnancy. Another impetus came from the New York State Department of Health, which in 2006 released practice guidelines on oral health during pregnancy that had been drafted by an expert panel of obstetricians and dentists. These guidelines call for prenatal care providers to refer all pregnant women who have not had a dental examination during the previous 6 months to an oral care provider. To help ensure that such referrals actually occurred for underserved women, the periodontist sought to establish a partnership among the PCAP clinics, hospitals, and private practice oral care providers.

    Did It Work?

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    Results

    The program has enhanced access to routine and followup dental care for thousands of low-income pregnant women, many of whom had significant tooth or gum problems that ended up being addressed.
    • Enhanced access to routine dental services: Since its inception in 2007, the program has provided routine oral care to more than 2,000 women, including about 350 in 2011. In the absence of this program, many of these women likely would have forgone treatment or their problems would have worsened until they were forced to seek emergency treatment.
    • Many problems identified and treated through followup care: For many women, the initial routine visit identified tooth or gum problems that required followup care. For example, a review of 320 patients seen during a 6-month stretch in 2008 found that 39.5 percent had gingivitis, with half of these individuals having a more advanced form of periodontal disease. Nearly one in five (17.5 percent) required a referral for emergency care (e.g., for pain and/or infection), and in one case the checkup identified a potentially fatal oral cancer. The same review found that three-quarters of the women followed their oral care provider's recommendation to return for followup visits during or after their pregnancy to have their problems treated, including the cancer patient who was able to access life-saving treatment.

    Evidence Rating (What is this?)

    Suggestive: The evidence consists of post-implementation data on the number of women receiving routine dental care through the program, and the proportion of these women in need of and receiving followup dental care; data on routine visits came from the periodontist's internal office records, while data on followup care came from a review of the charts of patients seen by the periodontist between April and September of 2008.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Forming alliance with hospitals and PCAP clinics: In late 2006, the periodontist met with administrators at North Shore and Long Island Jewish Hospitals about setting up a program in which he would provide basic dental care to pregnant women referred from the hospitals' PCAP clinics. They agreed to this approach and were amenable to having the hospitals' dental clinics provide emergency dental care when needed. Several hospital officials played key roles in championing the concept, including the chairman of the dental department and the director of the PCAP program at Long Island Jewish Hospital and the OB/GYN chairperson at North Shore Hospital. The periodontist also met with clinic staff to develop a standard referral form, and met with financial administrators to work out Medicaid-related payment issues.
    • Educating hospital staff: The periodontist educated relevant hospital staff about the guidelines and the need to direct eligible pregnant women to the PCAP clinics if not already enrolled. He addressed attending and resident obstetricians/gynecologists during grand rounds, and spoke to nurses, nurse practitioners, nurse midwives, and physician assistants at staff meetings.
    • Educating and partnering with area dentists: The periodontist spoke to as many area dentists and other dental professionals as possible in an attempt to raise awareness about the program and identify those willing to provide followup dental care to PCAP patients. For example, in 2007 he spoke to dentists, nurses, and dental hygienists at a conference sponsored by the Long Island Perinatal Form, a coalition of clinicians, administrators, and public health advocates.
    • Launching program: With all program components in place, the periodontist began seeing pregnant women referred through PCAP clinics at his private practice in August 2007.
    • Adding third hospital: In October 2008, the periodontist enlisted South Nassau Communities Hospital to participate in the program.

     

    Resources Used and Skills Needed

    • Staffing: In addition to the periodontist, dozens of health care and administrative employees play a role in the program, including staff at the PCAP clinics, hospital-based dental clinics, and participating dentist offices.
    • Costs: Medicaid covers most of the cost of the oral care that the women receive. Patients may pay for care (typically at a substantial discount) in cases where Medicaid does not fully cover the costs, such as for followup care more than 2 months after delivery.

    Tools and Other Resources

    The New York State Department of Health's practice guidelines on oral care during pregnancy and early childhood are available at http://www.health.ny.gov/publications/0824.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

    Adoption Considerations

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    Getting Started with This Innovation

    • Cultivate obstetricians: Obstetricians (and obstetric nurses) play a vital role in getting pregnant women to focus on prenatal oral health, since these women highly value their recommendations. Consequently, program organizers need to develop strong relationships with obstetricians and educate them about the importance of urging patients to see a dentist during pregnancy.
    • Sell merits of participating to dentists: Program organizers need to develop a network of dentists willing to provide followup care. This task can be challenging, since many dentists remain reluctant to treat pregnant women or Medicaid beneficiaries. Such resistance can be overcome by sharing research on the benefits of prenatal dental care, along with firsthand accounts demonstrating that treating pregnant women (including Medicaid beneficiaries) can enhance their practice.
    • Set up reminder system: To minimize missed appointments, administrative staff should contact patients several times in advance of their first appointment (including the day of the appointment). The periodontist has found that with multiple reminders, the rate of cancellations and missed appointments for those in the program does not differ significantly than for other patients.
    • Avoid preconceived notions: Some dentists who primarily treat patients with private insurance are wary of treating Medicaid patients, as they fear that patients from different socioeconomic groups will not interact well in the waiting room. The periodontist has not experienced this problem, as most people empathize with pregnant women.

    Sustaining This Innovation

    • Maintain culturally sensitive staff: Effective patient–provider communication is a critical component of high-quality prenatal dental care, particularly with respect to educating patients. To ensure effective communication, make sure that dental staff are culturally and linguistically competent to serve patients. For example, the periodontist employs a Spanish-speaking dental hygienist who plays a key role in educating his many Hispanic patients on the importance of good oral hygiene during pregnancy.
    • Expand slowly: Awareness of the program tends to spread rapidly among both patients and physicians, creating a steady stream of patients seeking dental checkups. However, before accepting too many patients for routine checkups, adequate infrastructure must be in place to provide needed followup care (both emergency and nonemergency). Otherwise, patients will quickly become frustrated, as they have nowhere to go for subsequent treatment.

    More Information

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    Contact the Innovator

    Steven J. Kerpen, DMD, MPH
    Clinical Assistant Professor
    School of Medicine at Hofstra University
    Adjunct Assistant, Clinical Professor
    Department of Epidemiology and Health Promotion
    NYU School of Dentistry
    833 Northern Boulevard, Suite 250
    Great Neck, NY 11021
    (516) 773-3727
    E-mail: skerpendmdmph@aol.com

    Innovator Disclosures

    Dr. Kerpen reported no financial interests or business/professional affiliations relevant to the work described in this profile.

    References/Related Articles

    Kerpen SJ, Burakoff R. Improving access to oral health care for pregnant women. A private practice model. NY State Dent J. 2009 Nov;75(6):34-6. [PubMed]

    Footnotes

    1 New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines. 2006. Available at: http://www.health.ny.gov/publications/0824.pdf.
    2 Samuelson R. Guest editorial. Grand Rounds in Oral Systemic Medicine. 2006;1(4):10-13.
    3 Boggess KA, Urlaub DM, Massey KE, et al. Oral hygiene practices and dental service utilization among pregnant women. J Am Dent Assoc. 2010 May;141(5):553-61. [PubMed]
    4 Kerpen SJ, Burakoff R. Improving access to oral health care for pregnant women. A private practice model. NY State Dent J. 2009 Nov;75(6):34-6. [PubMed]
    Comment on this Innovation

    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: February 27, 2013.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: February 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 15, 2014.
    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.

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