Improving Children's Access to Oral Health Services: The Oral Health Initiative

Although major improvements have been made in oral health during the 20th century, many children in minority groups, from families with low-income, and with special health care needs still do not receive the oral health services that they need. To address the problem, the Health Resources and Services Administration (HRSA), working with the Health Care Financing Administration (HCFA), has launched the Oral Health Initiative. The initiative seeks to strengthen oral health service-delivery systems, enhance collaboration among federal agencies, and provide states with the resources needed to improve the oral health of hard-to-reach children. HRSA's activities include enhancing programs, services, and training, such as expanding the number of direct-service dental programs; establishing or enhancing graduate training programs in pediatric and general dentistry and in dental public health; and funding training programs in dentistry to train dental public health leaders.     

Problems With Access to Dental Care for Medicaid-Insured Children: What Caregivers Think

OBJECTIVES: This study aimed to gain insight into the experiences, attitudes, and perceptions of a racially and ethnically diverse group of caregivers regarding barriers to dental care for their Medicaid-insured children. METHODS: Criterion-purposive sampling was used to select participants for 11 focus groups, which were conducted in North Carolina. Seventy-seven caregivers of diverse ethnic and racial backgrounds participated. Full recordings of sessions were obtained and transcribed. A comprehensive content review of all data, including line-by-line analysis, was conducted. RESULTS: Negative experiences with the dental care system discouraged many caregivers in the focus groups from obtaining dental services for their Medicaid-insured children. Searching for providers, arranging an appointment where choices were severely limited, and finding transportation left caregivers describing themselves as discouraged and exhausted. Caregivers who successfully negotiated these barriers felt that they encountered additional barriers in the dental care setting, including long waiting times and judgmental, disrespectful, and discriminatory behavior from staff and providers because of their race and public assistance status. CONCLUSIONS: Current proposals to solve the dental access problem probably will be insufficient until barriers identified by caregivers are addressed.     

Health Care Access for Children With Special Health Care Needs in California

Objectives: This study examines health care access for children with special health care needs (CSHCN) in California, one of the nation’s most populous and diverse states. Methods: Data are from the National Survey of Children with Special Health Care Needs (NS-CSHCN), a nationally representative survey of access for U.S. children fielded by the National Center for Health Statistics (NCHS). California CSHCN and those in California’s Medicaid program are compared with CSHCN elsewhere on child health need, family enabling factors, health care enabling factors, system outcomes, and children’s experiences with care. Multivariable analysis identifies family and health care factors associated with system outcomes and children’s experiences with health care. Results: California parents generally report poorer experiences with care, lower performance on systems outcomes, and fewer health care and family enabling factors. The magnitude of disparity is greatest for CSHCN in Medi-Cal, although lower-income privately insured CSHCN in California also have poorer access than their counterparts in other states. Among CSHCN in Medicaid, greater condition impact and adolescent age are associated with poorer experiences in California for most measures. Disparities between California and other states persist even adjusting for family and health care factors in multivariable analysis. Conclusions: Performance gaps in California stem from population differences and apparent administrative barriers. Several statewide initiatives are addressing system barriers through supports to providers and information to parents.     

Factors Associated with Health Care Access for Mississippi Children with Special Health Care Needs

Objectives: This purpose of the study was to examine the factors associated with access to routine care and to specialty care for Mississippi children with special health care needs (CSHCN). Methods: We analyzed data for Mississippi CSHCN from the 2001 National Survey of Children with Special Health Care Needs. Using a modified version of Andersen and Aday’s Behavioral Model of Health Services Use, we explored the relationship of independent variables (e.g., demographics, insurance, severity of illness) to dependent variables (did not obtain routine care, did not obtain specialty care). We conducted bivariate and logistic regression analyses using SAS and SUDAAN. Results: Based on self-reported data, with a 61% response rate, 66% of Mississippi CSHCN needed routine health care, and 52.8% needed specialty care. Of these children, 6.5% did not receive routine care and 9.3% did not receive specialty care. In a fully adjusted model, discontinuous insurance coverage was an important factor associated with not having obtained routine care (OR = 7.8; CI = 1.7–35.9) and specialty care (OR = 8.6; CI = 2.0–36.8). Children with a high illness severity rank were more likely to have not obtained routine care than children with a low rank (OR 1.4; CI = 1.1–1.9). Conclusions: It may be important to establish a health insurance safety net for families who lack insurance continuity since it appears that a lapse in insurance coverage impedes health care access. Further research is needed to understand the relationship between illness severity and lack of health care access, especially for children with special health care needs.     

Access to Oral Health Care: The Role of Federally Qualified Health Centers in Addressing Disparities and Expanding Access

Objectives. We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations.Methods. Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience.Results. We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high.Conclusions. These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services.The “silent epidemic” of poor oral health in America was highlighted by the US Surgeon General’s 2000 report, Oral Health in America, which also called attention to the disparities that persist in oral health status, access to care, and unmet need for dental care.1A Government Accountability Office report from the same year echoed the need to address oral health disparities, noting that oral health problems are the most prevalent chronic disease suffered by children despite being largely preventable.2 As with medical care, numerous studies also have found that both disease burden and access to oral health care are associated with income,3 race and ethnicity,4 language,5 and insurance status and type.6 These factors are associated with barriers to access in underserved communities such as affordability, lack of provider availability, inadequate transportation, and low health literacy around the need for oral health care. Whereas nationally almost 60% of individuals with high incomes had a dental visit in the past year, less than 30% of low-income patients (those with incomes below 200% of the federal poverty level) had a dental visit in the past year.7In the 2011 brief Advancing Oral Health in America, the Institute of Medicine (IOM) offered recommendations for improving access to oral health prevention and treatment services through a variety of mechanisms, including expanding the focus on oral health in primary care settings. Components of the strategy included training primary care providers to screen patients for emergent oral health issues, to assess patient risk for oral health problems, and to refer patients to dental professionals when appropriate. The IOM also called for improving oral health literacy through education efforts aimed at individuals, communities, and health care professionals. For example, community-wide public education campaigns were recommended to enhance awareness and knowledge about the causes and implications of oral disease and the importance of preventive oral health services. Building the health literacy of patients and promoting healthy behaviors may increase patient activation around these issues, especially when coupled with guidance on how to access oral health services in the community.8A subsequent IOM report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, suggested ways to narrow or eliminate disparities and improve the oral health status of vulnerable populations, guided by the principles that (1) oral health is essential to overall health and, thus, is an important part of comprehensive health care, and (2) any broad strategy to increase access to care should include components aimed at oral health promotion and disease prevention.9 Building on the existing literature, recommendations for improving access to oral health services for underserved individuals included expanding oral health care capacity by encouraging the integration of oral health services into overall health care.10 Improving dental education and training for nondental primary care providers may facilitate such integration.11 Financial and administrative barriers such as the lack of coverage for dental care need to be addressed, while supporting policies that encourage all professionals to practice to the full extent of their training and licensure.12Federally Qualified Health Centers (health centers) play a key role in these strategies as they are uniquely positioned to increase access to oral health services in the communities experiencing the most acute access problems. Health centers provided comprehensive primary care to 19.5 million patients in 2010, while also serving as an affordable and convenient access point to oral health services for underserved communities and populations. More than 3.8 million patients received dental services at health centers in 2010, and there were more than 9.2 million visits to dental providers employed in health centers.13All health centers are required to provide preventive dental services either on site or by referral, and 4 out of 5 health center grantee organizations provided dental services in at least 1 of their sites in 2010, and 62.0% provided emergency dental services on site.14 By enhancing affordability for needy patients and providing other services such as transportation, translation, and case management, health centers address barriers to access for the most vulnerable and underserved patients in the nation. In the report on underserved populations,9 the IOM specifically calls for health centers to utilize a variety of oral health care professionals in addition to dentists, to educate health center providers about best practices in oral health care, and to provide oral health services as part of outreach efforts beyond the walls of the health center.The oral health objectives in Healthy People 2020 are the guideposts for evaluating efforts to improve access to timely dental care and, ultimately, oral health status.15 The oral health goals in Healthy People 2020 seek to reduce the incidence and prevalence of dental problems by reducing delays and barriers to timely prevention and treatment, and 2 of the 17 oral health objectives specifically call for health centers to expand their role as a source of access to dental services. The first objective seeks to increase the proportion of health centers with on-site oral health care programs from 75% in 2007 to 83% by 2020. The second objective seeks to increase the proportion of health center patients that receive oral health services at their health center from 17.5% in 2007 to 33.3% by 2020.16 By 2010, 80% of grantees offered on-site oral health services in at least 1 site14 and 19.5% of health center patients received oral health services at their health center,13 demonstrating progress toward these goals.We examined data from the 2009 Health Center Patient Survey regarding access to oral health services among health center patients. We examined utilization and unmet need for oral health care, along with satisfaction with oral health care among health center patients.     

Children with Special Health Care Needs: How Immigrant Status is Related to Health Care Access,Health Care Utilization,and Health Status

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0–11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent’s language, parental education, ethnicity, and children’s insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.     

Disparities in Access to Easy-to-Use Services for Children with Special Health Care Needs

Objectives Families, clinicians and policymakers desire improved delivery of health and related services for children with special health care needs (CSHCN). We analyzed factors associated with ease of use in obtaining such services. We also explored what were specific difficulties or delays in receiving services. By examining data from the National Survey of Children with Special Health Care Needs (NS-CSHCN 2009–2010) and using the revised criteria for “ease of use,” we were able to assess the percentage of parents who reported that their experiences seeking services for their children met those criteria. Methods We performed Chi square tests to examine associations between the independent variables and their relationship to the difficulties or delays assessed in the survey; including: eligibility, availability of services, waiting lists, cost, and access to information. We used logistic regression to determine the association of meeting the “ease of use” criteria with socio-demographic, complexity of need, and access variables. Results Overall, a third of families of CSHCN (35.3 %) encounter difficulties, delays, or frustrations in obtaining health and related services. The lack of access to health and community services in this study fell most heavily on children from racial/ethnic minority backgrounds, those in poverty, and those with complex emotional/behavioral or developmental needs and functional limitations. Conclusions for Practice CSHCN require services from a broad array of providers across multiple systems. Unfortunately, there are certain difficulties that hamper the accessibility of these systems. These findings underscore the need for both practice-level response and systems-level reform to ensure equitable distribution of health and community resources.     

妇幼口腔卫生保健的家庭影响因素

为探讨家庭因素对幼儿口腔保健行为的影响，2002年6月下旬，江苏盐城市疾病预防控制中心在市机关幼儿园和城区机关幼儿园选择300名幼儿及其家长进行了调查。现将结果报告如下。     

Access to Health Care for Undocumented Migrant Children and Pregnant Women: The Paradox Between Values and Attitudes of Health Care Professionals

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children’s rights are needed to promote equitable practices and advocacy against regulations limiting services.     

Improving Access to Capital for Health Care Infrastructure: The Experience of the Southern Rural Access Program's Revolving Loan Fund

ABSTRACT: Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access
Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds fce. Key accomplishments are highlighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.     

Care Coordination Impacts on Access to Care for Children with Special Health Care Needs Enrolled in Medicaid and CHIP

Children with special health care needs (CSHCN) often require services from multiple health care providers. This study’s objective is to evaluate whether CSHCN, enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and receiving care coordination services, experience improved access to mental and specialty health care services. Using data from the 2009–2010 National Survey of Children with Special Health Care Needs, two separate outcomes are used to evaluate children’s access to care: receipt of needed mental and specialty care and timely access to services. Using propensity score matching, CSHCN propensity for receiving care coordination services is derived and an assessment is made of care coordination’s impact on the receipt of health care and whether care is delayed. Results demonstrate that care coordination is positively associated with whether a child receives the mental and specialty care that they need, regardless of whether or not that coordination is perceived to be adequate by parents. However, receiving care coordination services that parents perceive to be adequate has a larger impact on the timeliness in which care is received. This study indicates that care coordination is associated with an increased ability for CSHCN to access needed mental and specialty care. States should consider offering care coordination services that support provider communication and fulfill families’ coordination needs to the CSHCN enrolled in their Medicaid and CHIP programs.     

Improving Diabetes Care for Minority,Uninsured and Underserved Patients

A local safety net clinic provides pharmacy directed Diabetes Disease Management (DDM). The purpose of the study was to determine if a program like this would be successful in an underserved, uninsured poor minority population. Clinic providers referred patients to the DDM visits. Body Mass Index (BMI), low-density lipoprotein, high-density lipoprotein (HDL), triglycerides and hemoglobin A1c (HbA1c) were recorded pre- and post-intervention. Those who participated in pre-intervention and post-intervention visit were included in the study and laboratory values were compared. Participants in the pilot study showed statistically significant improvements in HbA1c, triglycerides and BMI. HDL values did not show statistical change. Pharmacy directed DDM can be effective in the reduction of HbA1c and triglycerides. It also may be an effective weight loss intervention for patients with diabetes.     

Empowering Head Start to Improve Access to Good Oral Health for Children from Low Income Families

Surveys over 20 years have documented worsening in the dental health of preschoolers. Healthy People 2010 Midcourse Review reports the country moving away from oral health goals for young children; the slip is 57%. Exacerbating this is the inability of Medicaid to provide for those in need. Most children receive examinations only: few receive comprehensive care. We urge Head Start grantees to adopt a new approach to oral health goals and in this paper offer: (1) a review of the problem and premises preventing a solution; (2) a proposal that Head Start adopt a public health perspective; and (3) specific roles staff and dental personnel can take to mount aggressive strategies to arrest tooth decay at the grantee site.     

Oral Health Care for Children in Countries Using Dental Therapists in Public,School-Based Programs,Contrasted with That of the United States,Using Dentists in a Private Practice Model

The United States faces a significant problem with access to oral health care, particularly for children. More than 50 countries have developed an alternative dental provider, a dental therapist, practicing in public, school-based programs, to address children’s access to care. This delivery model has been demonstrated to improve access to care and oral health outcomes while providing quality care economically.We summarize elements of a recent major review of the global literature on the use of dental therapists, “A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States.”We contrast the success of a school-based model of caring for children by dental therapists with that of the US model of dentists providing care for children in private practices.THE UNITED STATES’ ECOnomically disadvantaged children bear a disproportionate burden of dental disease. Although 40 million of the country’s 78 million children will be covered by public dental insurance by 2014, they will still suffer neglect because the overwhelming majority of dentists do not provide care for publicly insured children in their practices.1–3Interest is increasing in expanding the workforce to include the development and deployment of individuals with skills in caring for children traditionally associated with the school dental nurse/dental therapist.4–6 Using school dental nurses/dental therapists originated in New Zealand in 1921.7 The New Zealand model has subsequently spread to more than 50 countries.8,9 Dental therapists are typically deployed in school-based clinics to ensure access to dental care for all children.Dental therapists are highly skilled technicians, typically with 2 to 3 years of vocational training that emphasizes technical treatment skills and individual- and community-level prevention programs.9 Worldwide, their scope of practice includes examination, diagnosis, and treatment planning; exposing radiographs; oral health education; preventive services such as prophylaxis, fluoride therapy, fissure sealants, and dietary counseling; preparation of cavities in primary and permanent teeth and restoration with amalgam, composite, and preformed stainless steel crowns; and extraction of primary teeth. They have been successfully serving Native Americans in remote Alaskan villages since 2005.5,6 Minnesota authorized the training of dental therapists, with the first class graduating and beginning to care for its underserved populations in 2012.10 The development of dental therapists is supported by many US public health and philanthropic organizations, including the American Association of Public Health Dentistry11 and the American Public Health Association12 but opposed by the American Dental Association,13 most constituent state dental associations, the American Academy of Pediatric Dentistry,14 and other dental specialty organizations.It is possible that some of organized dentistry’s opposition to dental therapists is based on inadequate knowledge of their use and acceptance by the public and the dental profession in many other countries. To rectify this circumstance and provide an objective basis for consideration of introducing dental therapists in the United States, the W. K. Kellogg Foundation funded the University of Kentucky to conduct a study of the global literature on the use of dental therapists. The final report, “A Review of the Global Literature on Dental Therapists: In the Context of the Movement to Add Dental Therapists to the Oral Health Workforce in the United States,” was conducted by 17 international dental educators and public health officials and published online in April 2012.9 More than 1100 documents from the 54 countries using dental therapists were identified. The 460-page monograph relied heavily on annotations of the literature, mostly direct quotes or excerpts to minimize bias.We describe oral health outcomes for children participating in international, population-centered, public, school-based programs staffed by dental therapists and contrast them with outcomes from the individual-centered, private-practice model staffed by dentists in the United States. In these programs, dental therapists are supervised by dentists, with their range of services closely restricted to their scope of training and assessed abilities. Supervision is typically indirect, with clinical dentists available for consultation or referral as needed.