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Amy Brock Martin, DrPH Presentation to Public Health Consortium October 15. 2013

Forwarding Public Oral Health with Theoretically Framed Partnerships, Planning, Programs, and Policies. Amy Brock Martin, DrPH Presentation to Public Health Consortium October 15. 2013. Who we are…. South Carolina Rural Health Research Center

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Amy Brock Martin, DrPH Presentation to Public Health Consortium October 15. 2013

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  1. Forwarding Public Oral Health with Theoretically Framed Partnerships, Planning, Programs, and Policies Amy Brock Martin, DrPH Presentation to Public Health Consortium October 15. 2013

  2. Who we are… South Carolina Rural Health Research Center • 1 of 7 Rural Health Research Centers funded by the Health Resources and Services Administration • Administratively located in the Arnold School of Public Health at the University of South Carolina • Mission: to increase knowledge of the persistent inequities in health status among populations of the rural US, with an emphasis on factors related to socioeconomic status, race and ethnicity, and access to healthcare services.

  3. Presentation Overview • Introduce South Carolina’s demonstration of the Academic Health Department Model through the Division of Oral Health (DHEC) and SC Rural Health Research Center (SCRHRC) • Guiding principles of partnership • Theoretically-driven State Oral Health Plan • Collaborative leadership model of SC Oral Health Advisory Council and Coalition (SCOHACC) • Results of AHD Model • Policy & practice achievements • ROI (extramural funding) • Scientific contributions • Epidemiological impact • Rural disparities & what we are doing about them

  4. Why Public Oral Health Matters? Oral health disparities hurt everyone! Martin, AB et al. Dental Health Access to Care Among Rural Children, 2008, included in CD, also available at http://rhr.sph.sc.edu/report/(7-2)%20Dental%20Health%20and%20Access%20to%20Care%20Among%20Rural%20Children.pdf What are costly diagnoses to your states’ Medicaid programs? • Those who come early…Preemies Huck O, Tenenbaum H, Davideau JL. Relationship between periodontal diseases and preterm birth: recent epidemiological and biological data. Journal of Pregnancy, 2011, Article ID 164654. • Those who live long…Dementia/Alzheimer’s Manczak M, Reddy, PH. Abnormal interaction of oliomeric amyloid-beta with phosphorylated tau: Implications to synaptic disyfunction and neuronal damage. Journal of Alzheimer's Disease 36(2), 2013, DOI:10.3233/JAD-130275. • Those who with chronic disease…Diabetes & Cardiovascular Disease Leite RS, Marlow NM, Fernandes JK. Oral health and type 2 diabetes. American Journal of Medical Science. 2013 Apr;245(4):271-3.

  5. Dental Health Professional Shortage Areas, 2012

  6. Persistent Whole County Dental Health Professional Shortage Areas, 2009 - 2012

  7. Why Care About Safety Net Populations?

  8. IOM Academic Health Department • IOM called for agency/academic partnerships to ensure the effectiveness of public health in 1988 and 2003. • What is it? • According to ASPH, it is a “partnership between a school of public health (SPH) and a health department to create a dynamic academic-practice collaboration, which effectively pools assets of both institutions.”http://www.asph.org/UserFiles/AcademicHealthDepartments.pdf • HRSA determined poor responses by SPH & agencies to IOM call to action in 2005.

  9. South Carolina’s SOHP Proof of Concept • DHEC and SCRHRC began partnership in 2006, facilitated by CDC Cooperative Agreement, Strengthen State Oral Disease Prevention Programs. • $15K contract codified relationship, which has leveraged $5.2 million in oral health grants and programs (excludes national research grants) • State Oral Health Plan (SOHP) as catalyst • A collaborative leadership model with SCOHACC used to develop 5-year SOHP • PRECEDE-PROCEED was used to facilitate the SOHP.

  10. Predisposing Factors Health Promotion Health Education Reinforcing Factors Behavior & lifestyle Health Quality of Life Policy Regulation Organization Enabling Factors Environment SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999) Phase 2 Epidemiological Assessment Phase 1 Social Assessment Phase 5 Administrative & Policy Assessment Phase 4 Educational & Ecological Assessment Phase 3 Behavioral & Environmental Assessment Phase 6 Program Implementation Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation

  11. Workforce with public health competencies • Infrastructure & resources for change • Targeted outreach • Surveillance program • Interventions for special populations & chronic diseases • Workforce recruitment & incentive programs • Public demand for oral health improvements • Social marketing • Educational materials • Changes in oral health behavior, knowledge & values Improved oral health status of South Carolina citizenry Improved Quality of Life For All of SC • Availability of workforce & educators • Ability to pay for dental care • Political will for change • Effective Advisory Council & Coalition • Committed public leadership • Fluoridated Water • Educated, Strategic Dental Workforce • Public oral health infrastructure SOHP GENERAL THEORETICAL FRAMEWORK (Green and Kreuter, 1999) Phase 2 Epidemiological Assessment Phase 1 Social Assessment Phase 5 Administrative & Policy Assessment Phase 4 Educational & Ecological Assessment Phase 3 Behavioral & Environmental Assessment Phase 6 Program Implementation Phase 9 Outcome Evaluation Phase 7 Process Evaluation Phase 8 Impact Evaluation

  12. Partnership Guiding Principles • Funding opportunities should not drive the mission of DOH or SCOHACC • Remain focused on SOHP goals and objectives to avoid mission creep • Disseminate lessons learned through peer-reviewed venues • Focus on consensus building • Small funding opportunities should be used for credibility-building efforts that can be leveraged into larger, innovative grants • Respect partners’ expectations • e.g. academic needs for scholarly output, DHEC needs for epidemiological impact

  13. Summary of Policy & Practice Achievements since 2006 Act 235 Pew Rankings Congressional testimony NCSL Presentation OB guidelines School nurse dental screenings Community water fluoridation advocacy training Oral health integrated into Dept. of Ed. Health and Safety Standards Early childhood guidelines Fluoride varnish reimbursement policy (Medicaid) AAPD/Head Start Dental Home Leadership State

  14. Extramural Funding ($5,220,000)

  15. Results:Scientific Contributions • Presented 12 posters and conducted 5 invited oral presentations at state and national conferences (APHA, Academy Health, Academy for Health Equity, NOHC, AAP, SCRHA, James E. Clyburn Health Disparities Lecture) • Published 2 manuscripts in peer-reviewed journals (Maternal & Child Health Journal and Pediatric Dentistry) with 1 in development and 1 in R&R (APHA & Public Health Dentistry). • Influenced 3 national studies funded through the core RHRC grant: • National Rural Children’s Oral Health Disparities Chartbook (2008) • State Policy Levers for Addressing Preventive dental Care Disparities for Rural Children (2012) • Dental Sealant Utilization Among Rural and Urban Children (2013)

  16. OHNA Summary Results for 2012/2013Percent of Children by Indicator* Weighted analysis for public schools in K and 3rd grade. Sealants only include children in 3rd grade.

  17. Results: Epidemiology Impact

  18. Percent of Caries Experiences by Race/Ethnicity 2007* (p<0.0001 for race; ethnicity not calculated due to low observations) 2012* (p<0.0001 for race; p=0.01 for ethnicity)

  19. Percent of Caries Experiences by Medicaid Member Status 2007 2012* (p<0.0001)

  20. Percent of Caries Experiences by Free & Reduced Lunch Participation 2007* & 2012* (p<0.0001)

  21. Percent of Caries Experiences by Rural vs. Urban School 2007* (p<0.0001) 2012* (p=0.048)

  22. Percent of Sealants by Race/Ethnicity 2007 (no race differences; not calculated for ethnicity due to low observations) 2012* (no race differences; p=0.022 for ethnicity)

  23. Percent of Sealants by Medicaid Member Status 2007* (p<0.0001) 2012 No differences

  24. Percent of Sealants by Free & Reduced Lunch Participation 2007 & 2012 (No differences)

  25. Percent of Sealants by Rural vs. Urban School 2007 & 2012 (No differences)

  26. Percent of Untreated Caries by Race/Ethnicity 2007* (p<0.0001 for race; not calculated for ethnicity due to low observations) 2012* (No differences for race or ethnicity)

  27. Percent of Untreated Caries by Medicaid Member Status 2007 (No differences) 2012 (p=0.007)

  28. Percent of Untreated Caries by Free & Reduced Lunch Participation 2007* (p<0.0001) 2012 (No differences)

  29. Percent of Untreated Caries by Rural vs. Urban School 2007* (p<0.0001) 2012* (p=0.007)

  30. Percent of Tx Urgency 1 by Race/Ethnicity 2007* (p<0.0001 for race; not calculated for ethnicity due to low observations) 2012* (No differences for race or ethnicity)

  31. Percent of Tx Urgency 2 by Race/Ethnicity 2007* (p<0.0001 for race; not calculated for ethnicity due to low observations) 2012* (No differences for race or ethnicity)

  32. Percent of Tx Urgency 1 and 2 by Medicaid Member Status 2007 (No differences) 2012 (p=0.0111)

  33. Percent of Tx Urgency 1 and 2 by Free & Reduced Lunch Participation 2007 (p<0.0001) 2012 (No differences)

  34. Percent of Tx Urgency 1 and 2 by Rural vs. Urban 2007 (p<0.0001) 2012 (p=0.0083)

  35. OHNA Takeaways…how do we see the glass? Half Full • Caries experience has declined but disparities continue to exist • Untreated caries & Tx urgencies drop is sizeable • race, ethnicity, and F&RL disparities disappear! • Tx Urgency 2 is nearly eliminated Half Empty • Sealants improve a little with lots left to do • Rural disparities remain throughout the indicators, except sealants

  36. Addressing the rural disparities….

  37. South Carolina Act 235 (2010) Created the Community Oral Health Coordinator program (COHC) within DHEC. work with school nurses in a targeted community program to improve dental health in the state’s public schools. operate in three to five counties identified as dental health professional shortage areas. The program will provide dental health education, screening, and treatment referral for public school students in kindergarten, third, seventh, and tenth grades; or upon entry into a South Carolina school. provide community oral health education and training coordinate transportation and other non-clinical support to patients and their families link dentists who provide Medicaid services or would provide free or reduced-cost care to children identified by the screening that do not have a dental home help ensure that parents understand the importance of not missing appointments and the need for follow-up care provide a connection people in local communities with the tools they need to improve oral health NO FUNDING APPROPRIATED!

  38. HRSA Oral Health Workforce Grant • Teledentistry feasibility study • N=387 (21.5% response rate) • COHC Training Center • Community Water Fluoridation Advocacy • Rural Safety Net Expansion

  39. “Perfect Storm” of Opportunity 1. Oral Health 2014 Planning Grant – Sustainability Workgroup 2. MIECHV Grant 3. HRSA Oral Health Workforce Grant

  40. Oral Health 2014 – DentaQuest Foundation System-Level Goals • To increase the number of dentists who see children aged 0 to 3 years • To increase the number of physicians who apply fluoride varnish • To integrate community oral health coordination into the SC Maternal, Infant, and Early Childhood Home Visitation program • Increase the knowledge of early childhood oral health needs among the aforementioned providers using Smiles for Life • Increase the knowledge of COHC techniques among existing care coordinators in community systems, e.g. WIC, BabyNet, FQHCs etc. Person-Level Goals • Increase in the number of children aged 0 to 3 years with preventive dental services • Increase in the number of children receiving fluoride varnish from their medical home • Decrease in early childhood caries-related treatment • Increase parents’ perceived value of oral health services of children aged 0 to 3

  41. Predisposing Factors Health Promotion Health Education Reinforcing Factors Behavior & lifestyle Health Quality of Life Policy Regulation Organization Enabling Factors Environment How does DQF ‘ask’ align with the SOHP? PRECEDE-PROCEED Organized in the ‘Early Childhood’ Chapter Parents, MDs, & DMDs value oral health services for 0-3 Parents engaged in care & behaviors; med/dental interconnected Improved appropriate use of preventive oral health services Safety Net Ed COHC Ctr Flu advocacy DMD visit by 1; risk-based varnish received Improved oral health for kids 0-3 Access to fluoridated water & affordable, high quality oral health services Local fluoridation advocacy teams; adequate care capacity for 0-3 Engaged Stakeholder Collaboratives; COHC through MIECHV

  42. How does our DQF ‘ask’ align with Medicaid priorities? Triple Aim Model Source: Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Aff. May 2008. 27(3):759-69. Improved population health: • Reduction in early childhood caries Improved care experience: • DMD visit by age 1 with annual visits thereafter • Receipt of risk-based fluoride varnish Decreased per capita costs: • Increased overall savings to Medicaid due to increase in preventive service utilization Achievement of Triple Aim is contingent upon the following conditions: • Focus on a specific population • Consistency in approach/care for the specified population • Use of an organization (an “integrator”) that accepts responsibility for all three aims for that population. Berwick et al states the integrator’s role includes at least five components: • partnership with individuals and families, • redesign of primary care, (in our case, oral) • population health management, • financial management, and • macro system integration.

  43. Unanticipated Benefit • Public Health Leadership Development • Martin obtains public oral health practice experience • Former DOH Director (Veschusio) obtains technical training by entering the HSPM DrPH program • We have trained 7 graduate students with DOH through public health practica and graduate assistantships. • Valeria Carlson (HPEB) works for CDC • Gerta Ayers (HSPM) works for DOH and is currently interim director

  44. Summary – Facilitators of Success Deliberate (usually) delivers! Theoretically-driven strategic plan Mutually agreed upon guiding principles and expectations Data-driven solutions Leadership development

  45. Contact information Amy Brock Martin, Dr.P.H. brocka@mailbox.sc.edu SC Rural Health Research Center 220 Stoneridge Drive, Suite 204 Columbia, SC 29201 803-251-6317 (telephone) http://rhr.sph.sc.edu

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