SummaryA comprehensive, multi-stakeholder program in Washington State seeks to enhance access to dental services for Medicaid-eligible children younger than 6 years through training, enhanced reimbursement, and ongoing support for providers, combined with outreach, education, and support for eligible families. A statewide, locally run initiative known as Access to Baby and Child Dentistry, the program features dental champions at the local level who recruit, train, and certify local dentists for participation. Once certified, participating dentists receive higher than usual reimbursement from Medicaid for care provided to enrolled children, along with ongoing support in dealing with program-related challenges. Coordinators employed by county-level organizations reach out to eligible families, providing education and support in accessing a dental home for their young children. The program has enhanced access to dental care for young children (even those not enrolled in Access to Baby and Child Dentistry), leading to a decline in untreated tooth decay and lower costs. It has helped providers feel more comfortable serving young Medicaid patients, improved their attitudes about doing so, and generated high levels of satisfaction.Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the percentage of enrolled children receiving early preventive dental care and rates of untreated tooth decay. Other evidence includes Medicaid dental utilization data for children younger than age 6, post-implementation estimates of program-related cost savings, and anecdotal reports from providers about their satisfaction with the program and their attitudes and comfort level related to serving Medicaid enrollees.
Developing OrganizationsSpokane (WA) District Dental Society; Spokane (WA) Regional Health District; University of Washington School of Dentistry; Washington Dental Service Foundation; Washington State Health Care Authority (Medicaid)
Other partners include the Washington State Dental Association; the Washington State Department of Health; and various local health departments, community organizations, and private practice dentists.
Date First Implemented1995
The program began in Spokane County; as of 2013, all 39 counties in Washington have adopted the initiative.
Vulnerable Populations > Children; Impoverished; Age > Infant (1-23 months); Insurance Status > Medicaid; Age > Preschooler (2-5 years)
Problem AddressedDental care is the most prevalent unmet health care need among children.1 As a result, untreated tooth decay (i.e., dental caries) remains common in young children, particularly in minority and low-income families. Early preventive dental care can prevent tooth decay and reduce long-term dental care costs, yet many young children (especially low-income or minority children) do not receive it. Major barriers to care include dentists not knowing how to care for young children, families not understanding the importance of early dental care, and low Medicaid reimbursement.
- Many untreated cavities in young children: Nearly one-half of children (42 percent) between the ages of 2 and 11 have tooth decay in their primary (baby) teeth, including 23 percent with untreated cavities.2 Left untreated, dental caries can cause infection and pain that often lead to problems with eating, speaking, and learning.3
- Especially among low-income, minority children: Low-income and minority children are at increased risk of tooth decay. A Washington State survey of kindergarten and third-grade children found that 57 percent of minority children and 60 percent of low-income children had tooth decay, compared with 49 percent of all children.4
- Unrealized potential of early preventive care: Early preventive oral care reduces dental care costs for high-risk children by avoiding the need for restorative and emergency care.5 One study found that preschool children enrolled in Medicaid who received a preventive dental visit by age 1 were more likely to use preventive services and had lower dental care costs over a 5-year period ($262) than those who had their first visit later in life. (Five-year costs ranged between $339 and $546 for those first seen between the ages of 1 and 5, with costs rising as the delay in accessing care increases.5) Yet almost one-half of children between the ages of 2 and 5 and nearly one-fourth of those ages 2 to 11 have never been to the dentist, with minority and low-income children being less likely than Caucasian children and those in high-income families to have received dental care.6
- Caused by multiple barriers: Major barriers to receiving early preventive care include dentists not knowing how to care for young children, families not understanding the importance of oral care for their young children, and excessively low Medicaid reimbursement for preventive dental services.7 Another barrier is that many families with Medicaid-enrolled children are unaware that it includes dental benefits.
Description of the Innovative ActivityA comprehensive, multi-stakeholder program known as Access to Baby and Child Dentistry (ABCD) seeks to enhance access to dental services for Medicaid-eligible young children. A Statewide program administered at the county or regional level, the program features local program coordinators who work with dental champions to recruit and train dentists who then become certified for ABCD participation. Once certified, these dentists receive higher than usual Medicaid reimbursement for family oral health education and certain preventive and restorative procedures provided to enrolled children, along with ongoing assistance with program-related issues. Local coordinators reach out to eligible families, providing family orientation and support in accessing a participating practice and case-management, as required. While program details vary across sites, general elements include the following:
Figure 1. Washington's ABCD Programs in 2014 by county. Click the image to enlarge. Image courtesy of Washington Dental Service Foundation. Used with permission.
- Statewide initiative, with local administration: As of 2014, all 39 Washington counties have an ABCD program (see Figure 1). In each participating county, the local health department or a community agency (such as United Way or a Head Start program) runs the initiative. This organization employs a program coordinator who takes charge of the following: working with a local program champion to identify, train, and certify participating dental providers (described in more detail below); identifying eligible families and linking them to participating dental practices (also described in more detail below); managing program finances (e.g., budget preparation, identification of funding sources, fund management); developing an annual plan; meeting financial and reporting requirements required by the State’s Medicaid Program (i.e., the Health Care Authority); and serving as a program liaison for all stakeholders.
- Local champion-led recruitment, training, and certification of dentists: The local dental society and local program coordinator work with the University of Washington School of Dentistry to identify a dentist(s) to serve as the program champion(s) in the area, typically a pediatric dentist (or general dentist with an interest in child oral health) with strong ties to the community and experience treating Medicaid patients. After being calibrated by the university and receiving “train-the-trainer” instruction, the program champion works with the local program staff in recruiting and training interested dentists, as outlined below. As of 2008, primary care medical providers (including pediatricians, family physicians, physician assistants, and nurse practitioners) can also become certified, enabling them to receive reimbursement for oral screening, fluoride varnish, and oral health education during well-child visits, and make referrals to ABCD-certified dentists as necessary.
- Train-the-trainer program: The University of Washington School of Dentistry’s pediatric dentistry staff calibrates local champions in the ABCD dental curriculum and training of local dentists. Large counties may have several champions who split program responsibilities based on their skill sets (e.g., one may focus on recruiting/mentoring and another on training). Trained dentists are certified through the university and State Medicaid Program (WA Health Care Authority).
- Dental practice recruitment: Through his or her participation in professional events and general knowledge of the dental community, the champion, with local program assistance, identifies dentists who may be interested in participating, describes the program, and solicits interest. The local dental society may assist in this effort by sponsoring an initial and annual informational meeting for local dentists about the program, usually attended by ABCD State leaders.
- Dentist and office staff training: The local champion leads the University of Washington School of Dentistry–developed 3-hour training program in which local dentists and office staff learn how to provide dental care to young children in a culturally competent manner, and how to deal with Medicaid billing issues. Staff receive three continuing dental education credits for completing the program, which is outlined in more detail below:
- Care provision to young children: Dentists and their clinical staff learn strategies for effectively providing dental care to young children, including allowing the child to sit in a parent’s lap rather than the dental chair during an examination and other behavioral and clinical aspects of caring for young children.
- Cultural competence: Dentists and staff discuss strategies for communicating and interacting in a culturally appropriate and sensitive manner with families.
- Working with Medicaid: While dentists and other chair-side staff are trained in ABCD behavioral and clinical techniques, a concurrent session on ABCD/Medicaid billing procedures and protocols is provided to front office staff. Long term, the local ABCD program staff and the State Medicaid program support local dental practices in dealing with Medicaid billing issues and questions.
- Dental practice certification: To become an ABCD provider, a dentist must become a Medicaid provider and attend the ABCD certification training conducted by a dental champion under the auspices of the University of Washington Department of Pediatric Dentistry. ABCD trainings are held several times per year throughout the State. In some areas, trainings are offered in local dental offices. After training, the local ABCD program, University of Washington, and Health Care Authority work together to issue ABCD certification so trained providers can receive ABCD-enhanced fees.
- Enhanced reimbursement, ongoing assistance to facilitate participation: The program provides enhanced reimbursement to dental practices and ongoing assistance in dealing with program-related issues, as outlined below:
- Enhanced reimbursement for covered services: ABCD-certified dentists receive increased reimbursement from Medicaid for certain preventive and restorative procedures. In Washington State, Medicaid covers all preventive and select restorative dental services for children from birth through age 5 at enhanced rates. Examples of covered services include oral evaluation, family oral health education, fluoride varnish application, and cavity treatment. Reimbursement for a preventive examination to an ABCD provider is $29.46, whereas the non-ABCD rate is $21.73; the ABCD-enhanced rate for fluoride varnish is $23.41 whereas the non-ABCD rate is $13.25. (Certified primary care medical providers also qualify for this higher level of reimbursement for select services.)
- Ongoing assistance: The local coordinator helps practices troubleshoot issues related to ABCD program participation, such as resolving billing problems and overcoming challenges in working with patients. As needed, the coordinator will link the practice with staff at the Washington Dental Service Foundation, the University of Washington, and the Medicaid program. In smaller counties, the coordinator may proactively visit or telephone practices to inquire about program-related needs or problems. The local champion also serves as an ongoing resource, mentoring and sharing useful information about the program with participating practices, and may assist general dentists dealing with a complex clinical case with referral to a pediatric dentist.
- Patient enrollment, education, and link to services: The program coordinator takes charge of identifying eligible children, educating their families about the importance of early oral care, and linking children to a practice that matches their transportation, language, or family needs. The coordinator also offers ongoing case management services to those who have difficulty accessing care.
- Outreach to identify eligible children: The program conducts outreach in coordination with community organizations (such as Head Start programs; Women, Infant, and Children (WIC) nutrition programs; and community centers) to identify high-risk, low-income children who qualify for the program.
- Initial family education: The local program staff orients parents and children to the program and oral health—including discussion of proper oral home care (including the need for early preventive dental care), good eating habits, the importance of making and keeping dental appointments, and what to expect during a dental visit. Education may be conducted individually (either face to face or over the telephone) or in a group setting.
- Link to dental practice: The local program works with the family to identify as much as possible those ABCD providers who best fit their needs, including languages spoken or translation available, location, and office hours. The family selects a practice that is the best fit for their child and family. As part of their ongoing communication with the local program, participating practices can adjust the number of ABCD program enrollees they are able to accept; the practice has flexibility based on its overall caseload. In some counties, families can access a list of available providers on a Web site; in others, the coordinator shares a list of participating practices. In some cases, the coordinator may assist the family in scheduling the initial dental appointment.
- Ongoing case management: The local program provides ongoing case management services to families who have difficulty keeping dental appointments. The program addresses obstacles to care, such as lack of transportation and language barriers, and helps families move to a different dental practice if needed.
- Ongoing program review, sharing of best practices at all levels: State-level program leaders, the ABCD Leadership Group, meet annually to discuss program-related policies and strategies. Operational representatives from the same State-level partner organizations meet at least twice a year to discuss operational issues related to the program. Local program coordinators come together three times a year for program updates, learn about emerging issues and opportunities, and share best practices. In addition, the local dental champions come together once each year for a “Development Day” that provides an opportunity to participate in continuing dental education, share best practices, and provide feedback on the program.
Context of the InnovationThe Washington Dental Service Foundation is the State’s largest foundation focused on improving oral health. Funded by the Washington Dental Service (a nonprofit dental benefits company serving more than 2 million State residents), the Foundation supports a variety of programs to prevent oral disease, expand access to dental care, and increase awareness of the importance of oral health. The Department of Pediatric Dentistry within the University of Washington School of Dentistry promotes the oral health of infants, children, adolescents, and persons with special needs through service provision, education, and research. The Washington State Health Care Authority administers the state Medicaid program, which provides coverage to more than 1.3 million people (almost 500,000 of whom are children). The Washington State Dental Association has more than 4,000 members, representing more than 70 percent of practicing dentists in Washington. The Spokane Regional Health District is the local public health agency serving a population of more than 400,000 in Spokane County.
The impetus for the ABCD program dates back to 1994, when researchers in the Department of Pediatric Dentistry evaluated the oral health needs of children in Spokane County and identified a significant problem with access to care, particularly in young children (ages 0 through 5) enrolled in Medicaid. The Spokane District Dental Society took a leadership role in addressing the problem, in collaboration with representatives from the Spokane Regional Health District, the School of Dentistry, and Washington State’s Medicaid Program, to identify the barriers to receiving dental care. Major barriers included low Medicaid fee schedules, poor systems for linking patients to dental offices, parental fears regarding dental care, parents not understanding the need for dental care for their young children, families not understanding appropriate dental office etiquette (including the need to show up for appointments, as no-show rates were high), and lack of knowledge and skills among general dentists about how to care for young children. As noted, the program was initially launched in Spokane County in 1995. Subsequently, with the Foundation’s leadership, various stakeholders came together to spread the practice across Washington State, developing the ABCD program in a way that addressed each barrier.
ResultsThe program has enhanced access to dental care for young children covered by Medicaid (even those not enrolled in ABCD), leading to a decline in untreated tooth decay and lower costs. The program has helped providers feel more comfortable serving young Medicaid patients, improved their attitude about doing so, and generated high levels of satisfaction.
Moderate: The evidence consists primarily of pre- and post-implementation comparisons of the percentage of enrolled children receiving early preventive dental care and rates of untreated tooth decay. Other evidence includes Medicaid dental utilization data for children younger than age 6, post-implementation estimates of program-related cost savings, and anecdotal reports from providers about their satisfaction with the program and their attitudes and comfort level related to serving Medicaid enrollees.
Enhanced access to preventive dental care: The proportion of Medicaid-enrolled children ages 5 and younger who received dental care more than doubled after implementation of the program, from 21 percent in 1997 to 51.1 percent in 2012 (see Figure 2). In absolute terms, this increase translates into a fourfold jump in the number of Medicaid-enrolled young children receiving such services (which rose from 40,000 in 1997 to 165,000 in 2012). An analysis of dental claims found that 45 percent of young Medicaid-enrolled children in Washington counties with an ABCD program had at least one preventive dental visit, above the 36-percent rate in Washington counties without the program and the 37-percent rate among children with private insurance nationwide.
Figure 2: Washington has experienced steady growth in Medicaid utilization for children under ages 6, 2 and 1. Click the image to enlarge. Image courtesy of Washington Dental Service Foundation. Used with permission.
- Even for nonenrolled children: The program appears to have “spillover” benefits to Medicaid-eligible children not enrolled in ABCD. For example, in Stevens County, children covered by Medicaid but not enrolled in ABCD increased their use of dental care to a level comparable with that of those enrolled in ABCD. Researchers believe this spillover benefit stems from the program’s ability to spread awareness of the importance of preventive dental care across the community.
- Less untreated tooth decay: The proportion of low-income children in Head Start and the Early Childhood Education and Assistance Program with untreated tooth decay fell by 50 percent between 2005 and 2010, from 26 percent to 13 percent. The percentage of low-income children in Head Start and the Early Childhood Education and Assistance Program with tooth decay experience fell from 46 percent to 40 percent over the same time period.
- Significant estimated savings: The decline in untreated tooth decay saves an estimated $525 per child over a 5-year period (based on the average costs of tooth restoration in the Medicaid program). A 2005 analysis comparing ABCD participants in Spokane County with similar children in a nonparticipating county found that the program costs only $13.50 per child per year, less than one-fourth of what the State Medicaid program pays to restore one tooth with a cavity. This analysis suggests that the program saves money and provides a substantial return on investment.
- More comfortable and positive about serving Medicaid enrollees: Participating providers report being more comfortable caring for young children since receiving ABCD training. In addition, focus groups suggest that front office staff in participating practices have more positive perceptions of Medicaid enrollees than their peers in nonparticipating practices. Overall, participating providers have a highly favorable view of the program.
Planning and Development ProcessSelected steps included the following:
- Developing educational curriculum: University of Washington School of Dentistry pediatric dentistry professors developed a comprehensive teaching syllabus to educate Spokane County dentists and clinical staff on appropriate treatment practices for children younger than age 6 and orienting other staff regarding front office and billing procedures.
- Agreeing to raise Medicaid rates: To test the role of financial incentives in getting dentists to treat young children, Medicaid representatives agreed to raise rates for certain preventive and restorative services for children younger than age 6 and to add a new reimbursement code for family education for dental providers in Spokane County.
- Helping dental practices understand Medicaid: Because dentists expressed concerns about working with Medicaid (including misconceptions about delayed payments), the State Medicaid agency provided training for staff of participating practices and designated agency representatives who would promptly return calls from Spokane County dental offices.
- Evaluating Spokane program: University of Washington researchers conducted a formal evaluation of the program in Spokane County.
- Spreading program to other counties: In the late 1990s, leaders of the Washington Dental Service Foundation became interested in increasing use of dental services by young children enrolled in Medicaid in Yakima and Benton-Franklin counties. They had heard about the success of the ABCD program in Spokane County and thought it would be beneficial to replicate it in these counties. In 1999, the foundation provided grant funding to support the launch of the program in these areas, while Medicaid leaders agreed to increase reimbursement to dentists in these counties. These ABCD sites proved successful as well, and the program expanded over time across the State.
- Ongoing enhancement of training curriculum: The ABCD training curriculum is continually enhanced based on best practices in the oral care field. In addition, the University of Washington is developing a refresher course for certified practices.
- Offering participation to medical providers: In 2007, Washington State passed legislation on child health care coverage that included provisions for enhanced Medicaid reimbursement for pediatricians and family physicians who provide preventive oral care services to young children during well-child visits. As an adjunct to this program, the Washington Dental Service Foundation trains primary care providers to deliver this care.
Resources Used and Skills Needed
- Staffing: Housed at the Washington Dental Service Foundation, the central ABCD program has support from a part-time managing director and other foundation staff in program activities that include development and operations, analysis and evaluation, training and work with the State government. The University of Washington has several staff members who work with curriculum, provider training and certification, and dental champion support. The State Health Care Authority’s Dental Program Administrator and staff spend a portion of their time on provider certification, billing training, and billing issues resolution. Local program office staffing varies by county; in small counties, a part-time coordinator handles all program functions, whereas larger counties might require one or more full-time equivalent staff members. Dentists volunteer their time as program champions.
- Costs: Management of the State program averages $125,000 annually for Washington Dental Service Foundation, the State program’s managing partner. Local program startup costs vary widely depending on the size of the county; major costs are those associated with program staffing and the purchase of basic office equipment. In a small county, program operating expenses can be as little as $10,000 per year whereas a few of Washington’s larger counties have budgets of up to $100,000. The primary costs consist of staff salary and benefits, program marketing, and local coordinator travel (e.g., mileage reimbursement). As noted earlier, evidence to date suggests that the program reduces overall long-term dental costs, as program-related expenses are more than made up for by reductions in the costs of treating dental caries and other oral health problems.
Funding SourcesWashington Dental Service Foundation; Washington State Health Care Authority (Medicaid)
The Washington Dental Service Foundation offers grants that cover a substantial portion of program-related costs during the first years of operation; grants range from $10,000 to $400,000, with the funding distributed over a 3-year period. Other funding sources (e.g., local foundations, local United Way programs) vary across counties. The Washington State Health Care Authority (Medicaid) contracts with 29 agencies to manage the local ABCD program in a county or region; these local contracts range from $10,000 to $80,000 annually, based on the number of Medicaid-enrolled children ages 0 to 5 who reside there.
Tools and Other ResourcesVarious oral health policies and clinical care guidelines from the American Academy of Pediatric Dentistry are available at http://www.aapd.org/policies/.
Getting Started with This Innovation
- Address all barriers in program design: To maximize effectiveness, program developers should identify all major barriers to oral care and design the program to address each of them.
- Pursue State government support to raise rates: Adequate payment to providers is critical to ensuring access to comprehensive dental care for young Medicaid enrollees. As noted, Medicaid representatives in Washington State became concerned about low use of dental services by young enrollees, and hence were amenable to raising rates. However, even if Medicaid representatives support higher rates, in most States legislation or administrative action will be required to increase reimbursement.
- Engage broad coalition of stakeholders: Engage a broad array of child advocates by emphasizing the importance of oral health to young children and the need for both higher reimbursement and better access to care. Once advocates have been identified, program leaders should develop formal and informal methods to communicate with them, including vehicles that allow them to discuss and share ideas on how to maximize the impact of the program.
- Clearly delineate roles: Although ABCD is a partnership, program leaders should decide which organization would serve as “managing partner” (i.e., the “home” for the program and the main conduit for information about it). Program leaders should also delineate accountability for major program components, such as provider recruitment and training, outreach to eligible families, reporting, and other activities.
- Partner with Medicaid administrators: Medicaid administrators should be engaged as full partners in the program, including development of all aspects of the program (not just reimbursement issues).
- Identify effective local champions: Effective local dental champions typically have strong formal and informal relationships with other dentists and medical professionals in the community.
Sustaining This Innovation
- Cultivate champions: Ensure that local dental champions remain engaged by keeping them updated on program activities and providing them with ongoing continuing education. These champions often become passionate about the program and can be called upon to talk with State legislators, county boards of health, and others, as necessary.
- Actively pursue funding: Local programs need ongoing, long-term funding to remain successful. To that end, leaders should actively seek funding to allow operations to continue after startup grant funds are no longer available. In a difficult economic environment where State budgets face cuts, program leaders need to take an active advocacy role by highlighting the program’s positive outcomes, including its ability to reduce overall Medicaid costs and hence save money for the State.
- Monitor and respond to threats and opportunities: Be vigilant in identifying and responding to opportunities to expand or enhance the program, along with any threats to its ongoing funding and operation.
- Be patient and persistent: It takes time (at the least, several years) for this kind of program to gain momentum and have a demonstrable impact on outcomes. During this time, address problems as they arise and be open to new ideas when initial efforts do not work.
Spreading This InnovationIn 2013, the Washington ABCD Program success in increasing provider participation and Medicaid utilization for young children was shared with the other states Medicaid Dental Program leaders as a national CMS (Centers for Medicare and Medicaid Services) webinar presentation designed to support states in improving access to dental services for Medicaid-enrolled children.
Additional ConsiderationsIn 2001, the American Academy of Pediatric Dentistry recognized ABCD as a “best practice,” and, in 2010, the Pew Center on the States recognized it as a “proven strategy that can help policy makers prevent negative consequences and deliver a strong return on taxpayer investment.”
Contact the InnovatorLaura Smith, MPA
President & CEO
Washington Dental Service Foundation
9706 4th Avenue Northeast
Seattle, WA 98115
Access to Baby and Child Dentistry (ABCD) Program
Washington Dental Service Foundation
Innovator DisclosuresMs. Smith and Ms. O’Meara-Wyman reported having no financial interests or business or professional affiliations relevant to the work described in this profile, other than the funders listed in the Funding Sources section.
References/Related ArticlesAdditional information on Washington’s ABCD program is available at http://abcd-dental.org/.
Kobayashi M, Chi D, Coldwell SE, et al. The effectiveness and estimated costs of the Access to Baby and Child Dentistry program in Washington state. J Am Dent Assoc. 2005;136(9):1257-63. [PubMed]
The Pew Center on the States. Washington’s ABCD program: Improving dental care for Medicaid-insured children, 2010. Available at: http://www.pewstates.org/research/reports/washingtons-abcd-program-85899373157.
Lewis C, Teeple E, Robertson A, et al. Preventive dental care for young, Medicaid-insured children in Washington state. Pediatrics. 2009;124(1):e120-7. [PubMed]
Donahue GJ, Waddell N, Plough AL, et al. The ABCDs of treating the most prevalent childhood disease. Am J Public Health. 2005;95(8):1322-4. [PubMed]
Savage MF, Lee JY, Kotch JB, et al. Early preventive dental visits: effect on subsequent utilization and costs. Pediatrics. 2004;114(4):e418-23. [PubMed]
Kaakko T, Skaret E, Getz T, et al. An ABCD program to increase access to dental care for children enrolled in Medicaid in a rural county. J Public Health Dent. 2002;62(1):45-50. [PubMed]
Grembowski D, Milgrom PM. Increasing access to dental care for Medicaid preschool children: the Access to Baby and Child Dentistry (ABCD) program. Public Health Rep. 2000;115(5):448-59. [PubMed]
Lam M, Riedy CA, Milgrom P. Improving access for Medicaid-insured children: focus on front-office personnel. J Am Dent Assoc. 1999;130(3):365-73. [PubMed]
Newacheck PW, Hughes DC, Hung YY, et al. The unmet health needs of America's children. Pediatrics. 2000;105:989-97. [PubMed]
4 Washington State Smile Survey. Washington State Department of Health; Olympia, WA; 2010. Department of Health Publication No. 160-099.
Lee JY, Bouwens TJ, Savage MF, et al. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006;28(2):102-5. [PubMed]
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Original publication: February 27, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 19, 2014.
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