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Service Delivery Innovation Profile

Program Offering Free Dental Care in Exchange for Community Service Significantly Reduces Dental-Related Emergency Department Visits by Uninsured Individuals


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Snapshot

Summary

The Dentists’ Partnership in Battle Creek, MI, provides free oral health care to low-income, uninsured individuals in exchange for community service. Approximately 70 percent of the dentists in the county (43 dentists) commit to treating a certain number of patients each month on a volunteer basis and specify which services they will offer. Patients can self-refer to the program or be referred by local emergency departments and social service agencies. Interested patients attend a mandatory 2-hour education class and receive a screening, x-rays, and cleaning from a dental hygienist employed by the program. A dentist then evaluates the patient and develops an action plan outlining needed services. To receive the services, the patient must complete volunteer hours at local nonprofit organizations, with the required number of hours based on the value of the dental services needed. The program has enhanced access to dental services for low-income individuals, providing roughly $750,000 worth of dental services to approximately 3,300 people who otherwise would not have access to such care. As a result, the number of low-income patients presenting to the emergency department with dental complaints has fallen by 70 percent. The program has also created a positive return on investment, enhanced the level of community service provided to local nonprofit organizations, and generated high levels of dentist and patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of emergency department visits for dental pain, along with post-implementation data on various metrics, including the number of clients served, the value of dental services provided to these clients, no-show rates, hours of volunteer service provided to the community, the program's estimated return on investment, and anecdotal reports from patients and dentists about their satisfaction with the program.
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Developing Organizations

Battle Creek Community Foundation - Regional Health Alliance; Bronson Battle Creek Hospital; Community HealthCare Connections
All listed organizations are located in Battle Creek, MI.end do

Use By Other Organizations

Representatives from more than 30 communities have contacted the Dentists’ Partnership to express interest in replicating the program. To date, 13 communities in the Midwest have done so, including Springfield, MO, and South Bend, IN.

Date First Implemented

2007
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Patient Population

Vulnerable Populations > Impoverished; Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Many low-income adults have little or no coverage for preventive dental care and consequently do not get such care. As a result, they frequently visit the emergency department (ED) for urgent oral care needs, such as infections and dental pain.
  • Lack of dental coverage for low-income individuals: According to the Kaiser Family Foundation, more than 73 percent of low-income adults under the age of 65 lack dental coverage.1
  • Lack of preventive oral care: Compared with high-income adults, low-income adults are much more likely to forgo routine or preventive dental care; in 2010, 42 percent of adults with incomes below 200 percent of the Federal poverty level had seen a dentist in the past year, compared with 70 percent of adults with income levels above 200 percent of the Federal poverty level.1
  • Many ED visits for acute dental needs: Many low-income individuals without dental coverage experience dental pain and oral health emergencies that could have been prevented with early detection and treatment.2 Between 2000 and 2010, the number of annual dental-related visits  to hospital EDs nearly doubled, from 1.1 to 2.1 million. Patients visiting the ED with acute dental needs are most likely to be young or middle-aged adults who are uninsured or are Medicaid beneficiaries with little or no dental coverage.2 ED physicians can prescribe antibiotics or pain medication to these patients but cannot manage the underlying dental problem. As a result, many of these patients return to the ED.

What They Did

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Description of the Innovative Activity

The Dentists’ Partnership in Battle Creek, MI, provides free oral health care to low-income, uninsured individuals in exchange for community service. Approximately 70 percent of the dentists in the county commit to treating a certain number of patients each month on a volunteer basis and specify which services they will offer. Patients can self-refer to the program or be referred by local ED clinicians and social service agencies. Interested patients attend a mandatory 2-hour education class and receive a screening, x-rays, and cleaning from a dental hygienist employed by the program. A participating dentist then evaluates the patient and develops an action plan outlining needed services. To receive the services, the patient must complete volunteer hours at local nonprofit organizations, with the required number of hours based on the value of the dental services needed. Key program elements include the following:
  • Dentist-determined monthly commitment to treat uninsured patients: Dentists interested in participating fill out a form by which they commit to handling a certain number of visits from eligible patients each month. They choose one of three levels of participation depending on how much time they want to commit: 2 to 3 visits, 4 to 7 visits, or 8+ visits. On the same form they specify what type of services they will provide, such as fillings, tooth extractions, and root canals. Dentists are eligible to receive a $1,000 commitment bonus when they sign a letter agreeing to participate, although most dentists do not accept this money. Dentists committing at the second and third levels receive a $1,000 or $2,000 annual resource-fund bonus that they can use to buy equipment and supplies or invest in staff training. To date, 43 dentists (70 percent of all dentists in the county) have agreed to participate in the program.
  • Patient referrals: ED physicians and staff tell low-income patients who present to the ED with dental problems about the program and refer interested patients to it. Patients who express interest sign a records-release form, which the hospital faxes to Community HealthCare Connections (CHC), a nonprofit organization serving Calhoun County that administers the program. CHC also receives referrals from other sources, including other local health care providers and social service agencies. Patients can also self-refer to the program.
  • Eligibility verification and enrollment: CHC staff make up to three attempts to reach the patient, beginning with a telephone call followed by two letters. Once contact is made, the patient visits the CHC office where staff verify eligibility, explain the volunteer commitment, and distribute the volunteer tracking sheet, as outlined below:
    • Eligibility verification: The program serves those with incomes below 200 percent of the Federal poverty level (roughly $24,000 in 2013) who are not eligible for Medicaid or other forms of public insurance. CHC staff verify the patient’s income and whether they qualify for any public insurance programs, including Medicaid. For those that do, they assist with the enrollment process and refer the individual to the local Federally qualified health center to receive dental care.
    • Explanation of volunteer commitment: CHC staff explain the volunteer commitment to the patient, who must agree to perform community service in exchange for dental care. Each hour of volunteering allows the patient to receive $25 worth of care, meaning that a dental screening/cleaning, filling, or tooth extraction, which cost $100 each, require four volunteer hours. To fulfill their requirement, patients may volunteer at any local nonprofit organization, including churches and schools.
    • Volunteer tracking sheet: At the enrollment meeting, patients receive a volunteer tracking sheet that lists contact information for community organizations that accept volunteers and for Hands on Battle Creek, a local agency that coordinates volunteer services. After volunteering, the patient asks a responsible person at the volunteer site to sign the tracking sheet and indicate the number of hours worked. The patient must bring the signed sheet to CHC to receive dental services.
  • Mandatory education class: Prior to receiving any care, patients must attend a mandatory class led by a dental hygienist who provides basic oral health information; discusses proper oral self-care; distributes toothpaste, toothbrushes and dental floss; and explains expectations related to a dental visit, such as brushing one's teeth beforehand, being on time, and exhibiting courteous behavior. Patients receive 2 hours of volunteer credit if they bring a friend or family member to the class. In the absence of an emergency care need, patients must earn at least 4 hours before they can move to the next step, screening and cleaning.
  • Screening and cleaning by hygienist: After completing 4 volunteer hours, patients are scheduled for a visit with a dental hygienist in the dental treatment room at the CHC site. Employed by CHC, the hygienist creates a dental chart, reviews the patient’s health history, performs a general dental screening, takes x-rays, and provides a cleaning.
  • Initial examination by dentist: After the visit with the hygienist, CHC staff refer the patient to a participating dentist for an evaluation, sending the patient's chart to the office in advance of the scheduled visit via courier. The dentist performs an initial examination and creates a prioritized action plan based on the patient’s needs. After the visit, the dentist returns the chart with the action plan to CHC.
  • Determination of required volunteer hours: CHC staff review the action plan and determine the number of volunteer hours required to obtain the needed services. Staff then communicate this information to the patient.
  • Volunteer service prior to receiving treatment: Except in emergency cases, participants must complete the required hours prior to receiving treatment. Some patients volunteer the number of hours needed to receive the care they currently need, while others accrue additional volunteer hours to be used for future dental services. A friend or family member may complete community service hours on behalf of a patient unable to do so.
  • Scheduling appointment for treatment: Once the patient completes the requisite number of hours and returns the signed tracking sheet to the CHC office, staff schedule an appointment with a dentist who offers the needed treatment and has not yet met his or her committed hours for the month. (This individual may not be the same dentist who performed the initial evaluation). CHC staff send the patient’s dental chart to the dentist’s office via courier in advance of the appointment.
  • Transportation if necessary: If necessary, CHC provides bus tokens or gasoline vouchers to help patients attend their volunteer commitments and dental appointments.

Context of the Innovation

CHC administers a number of public and nonprofit health programs that connect uninsured and underinsured individuals in Calhoun County, Michigan, to urgent medical care and to health, navigation, and advocacy services. The county is home to roughly 136,000 residents, 13.6 percent of whom live at or below the Federal poverty line.

The Regional Health Alliance is sponsored by the Battle Creek Community Foundation, which develops various community health and quality-of-life initiatives in the county. The Regional Health Alliance has formed several workgroups that focus on specific topics, including the Dental Access Initiative Group. In 2006, a member of this group (a statistician at Battle Creek Health System) discovered that 111 uninsured residents visit the Bronson Battle Creek Hospital ED each month seeking care for dental pain and infection. After seeing this figure, workgroup members, including the executive director of CHC, interviewed local ED physicians, other doctors, and dentists about this issue. These conversations confirmed that many low-income residents in the county had unmet dental care needs, which in turn convinced the group of the need to launch the Dentists’ Partnership program.

Did It Work?

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Results

The program has enhanced access to dental services for low-income individuals, having since its inception provided roughly $750,000 worth of dental services to approximately 3,300 people who otherwise would not have access to such care. As a result, the number of low-income patients presenting to the ED with dental complaints has fallen by 70 percent. The program has also created a positive return on investment, enhanced the level of community service provided to local nonprofit organizations, and generated high levels of dentist and patient satisfaction.
  • Many clients served: Between its launch in 2007 and June 2012, the program has provided $750,000 worth of dental services to 3,319 patients, the vast majority of whom would not have had access to such services in the absence of this program.
  • Significant decline in ED visits: The rate at which patients visit the ED for dental pain has fallen by 70 percent since the program began, from 26.5 per 1,000 ED visits in 2006 (the year before implementation) to 7.5 per 1,000 ED visits in 2012. The recidivism rate (the percentage of patients who come back to the ED for emergency dental care) is under 2 percent.
  • Positive return on investment: A 5-year analysis found that the program generates a return on investment of 322 percent, meaning that it produces $3.22 in benefits for every dollar invested. This analysis includes the value of donated dental services and materials and the value of volunteer hours in the program's costs.
  • Enhanced community service: Since the program began, participating patients have provided more than 55,000 hours of community service to more than 70 local nonprofit organizations.
  • High patient and dentist satisfaction (including with no-show rates): Participating patients report positive benefits from the program that go beyond the value of the dental services received, including feelings of increased self-worth and community involvement. Dentists also express high levels of satisfaction with the program, noting in particular the good feelings they have when patients express gratitude for their care. Their high satisfaction stems in part from the very low no-show rates among participating patients (no-shows can be very disruptive to their schedules). While some dentists initially expressed concern about the potential for high no-show rates among low-income patients, this concern never materialized. In fact, only 2.5 percent of participating patients fail to show up, well below the 20-percent average for commercially insured patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of emergency department visits for dental pain, along with post-implementation data on various metrics, including the number of clients served, the value of dental services provided to these clients, no-show rates, hours of volunteer service provided to the community, the program's estimated return on investment, and anecdotal reports from patients and dentists about their satisfaction with the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Interviewing local dentists to identify barriers to care: Members of the Dental Access Initiative Group interviewed local dentists to identify barriers to providing charitable care, such as the administrative burden associated with income verification and concerns about high no-show rates.
  • Designing program: Based on the interviews, the group designed a proposal for an initiative in which dentists provide free care to low-income patients in exchange for patients volunteering in the community. Group members agreed that CHC was the logical administrative home for the initiative. They presented the proposal to Regional Health Alliance leaders, who approved it.
  • Developing referral process: CHC and Bronson Battle Creek Hospital signed a business agreement to allow ED staff to share relevant patient health and contact information when making referrals. Initially, the hospital faxed a list of referred patients to CHC each month. As noted earlier, patients now sign a release form that is faxed the same day.
  • Recruiting dentists: Program developers contacted local dentists to explain the program and secure their participation, including discussing the number of uninsured patients they could handle each month and the services they could provide to them. Initially, 10 dentists agreed to participate in a pilot test of the program. Over time, word-of-mouth among colleagues and local outreach by program staff (including one-on-one meetings with dentists and presentations at Michigan Dental Association meetings) helped expand the number of volunteer dentists.
  • Developing oral hygiene class: Based on feedback from dentists, program developers created an oral hygiene class to educate patients about preventive self-care and to set expectations for the dental visit.
  • Expanding program: Since the program's inception it has grown to include an orthodontia program and denture services. In 2012, a chiropractic initiative was patterned after the Dentists' Partnership.

Resources Used and Skills Needed

  • Staffing: CHC hired one part-time hygienist to provide screenings, cleanings, and x-rays and a program coordinator who manages the logistics of enrollment, scheduling, and chart delivery. A second part-time hygienist for the program is provided by the Fountain Clinic, another free clinic in the county.
  • Costs: Operational costs total approximately $130,500 annually, including compensation to the hygienists, time devoted to the program by the two CHC staff members, and other expenses, such as dental supplies, office supplies, marketing, and training.
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Funding Sources

United Way; Bronson Battle Creek Hospital; Battle Creek Community Foundation
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Adoption Considerations

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Getting Started with This Innovation

  • Hire dedicated hygienists if State regulations allow: Michigan is one of approximately 30 States that allow hygienists to work under indirect supervision by a dentist (i.e., the dentist and hygienist can work in different locations as long as the dentist is readily available for remote consultation). By hiring and paying for hygienists separately (rather than relying on hygienists employed by participating dental practices), program leaders can reduce the burden on dentists, including the amount of time they must spend with each patient.
  • Let dentists choose desired level of participation: Give dentists various options as to the number of uninsured patients they will take each month and let them decide which services they will make available to these patients.
  • Find outside organization to handle administration: If possible, identify a local organization that already provides services to the uninsured to assume administrative responsibility for the program. By handling eligibility requirements, referrals, and (if possible) initial screenings through employed hygienists, this organization can minimize the burden for dentists, thereby increasing the likelihood that they will agree to participate.
  • Incorporate education into program: The oral hygiene class offers valuable and necessary information to vulnerable populations and reduces the time burden for participating dental practices. The class also informs patients of what will be expected of them during the visit, helping to ensure a pleasant experience for both dentist and patient.

Sustaining This Innovation

  • Maintain equitable caseload: Balance referrals so that participating dentists share the caseload and can work patients into their existing schedules and workflow.
  • Track performance and share successes: Sharing data documenting the program's positive impact on ED visits, its low no-show rates, and other metrics will help generate interest and ongoing support by dentists and potential funders. In Battle Creek, dentists' willingness to continue participating in the program is due in large part to the low no-show rate by participating patients. Program leaders believe this low rate results from requiring patients to meet their volunteer commitments before they can receive needed dental services.
  • Continue local outreach to dentists: By regularly visiting local dental offices and making presentations at local dental association meetings, program leaders can help to ensure that an adequate supply of dentists is available to meet uninsured patients' needs.

Use By Other Organizations

Representatives from more than 30 communities have contacted the Dentists’ Partnership to express interest in replicating the program. To date, 13 communities in the Midwest have done so, including Springfield, MO, and South Bend, IN.

More Information

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Contact the Innovator

Teresa Osborne
Director of Community Relations
Community HealthCare Connections
190 East Michigan Avenue, Suite 385
Battle Creek, MI 49014
(269) 969-6862
E-mail: tosborne@chcconnections.org

Innovator Disclosures

Ms. Osborne reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

Recognition

CHC’s executive director, Samantha Pearl, received the Public Service Award from the Michigan Dental Association in recognition of the organization’s work on the Dentists’ Partnership.

References/Related Articles

Community HealthCare Connections Web site. Available at: www.CHCconnections.org.

Higbea RJ, Palumbo CH, Pearl SA, et al. Dentists' partnership of Michigan's Calhoun County: a care model for uninsured populations. Health Aff (Millwood). 2013;32(9):1646-51. [PubMed]

Galewitz P. Uninsured in Mich. County can pay for dental care with volunteer work. Kaiser Health News. Henry J. Kaiser Family Foundation. November 17, 2013. Available at: http://www.kaiserhealthnews.org/Stories/2013/November/18/michigan-uninsured-dental-volunteer.aspx.

Footnotes

1 Kaiser Commission on Medicaid and the Uninsured. Oral health and low-income nonelderly adults: a review of coverage and access, Policy Brief. Kaiser Family Foundation. June 2012. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7798-02.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Wall T, Nasseh K. Dental-related emergency department visits on the increase in the United States. American Dental Association Health Policy Resources Center Research Brief. May 2013. Available at: http://www.ada.org/sections/professionalResources/pdfs/HPRCBrief_0513_1.pdf.
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Original publication: June 18, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.