Reducing Oral Health Disparities in Rural Communities through Telehealth Innovations Sarah Wovcha, JD, MPH, Executive Director Minneapolis, MN
Mission: Since 1919 Children's Dental Services is dedicated to improving the oral health of children from families with low incomes by providing accessible treatment and education to our diverse community.
Children’s Dental Services History Grew out of 1919 Minneapolis charitable women’s organization to serve destitute orphans when health safety nets were non-existent First in Minnesota to apply dental sealants in 1966 First in nation to provide on-site services in Head Start centers Over 10,000 rural patients and 50 rural partners annually request CDS’ care
Children’s Dental Services • • Provides care targeted to the following Target population: low-income children ages birth to 26 and pregnant women of patient groups: • Blind all ages • disabled • • Autistic Largest provider of on-site dental care in • HIV positive Minnesota schools and Head Start • Drug addicted centers • Homeless • • East African Quadrupled in size since 2000 due to the • Latino growing numbers of patients requesting • Southeast Asian services • Native American
Service Area and Statistics 633 sites 36,748 patients 63,000 visits 94,000 procedures
2017 Patient Demographics Note: 80% of sliding scale patients receive free care
Cultural Competency • CDS provides culturally targeted and translated dental services and education • CDS is particularly well equipped to serve multilingual, culturally-diverse families 125 staff 26 languages spoken 60% people of color 90% female
Barriers to Providing Services Swelling population of underserved patients High numbers of untreated immigrants/refugees Lack of funding- Minnesota’s Medical Assistance reimbursement rates among the lowest in nation (CDS 2017 uncompensated care write off exceeded $6.4 million) Difficulty hiring and retaining dentists (DDS) Results: As of 2015 only 37.2% of Minnesota children receiving Medical Assistance were able to see dentist
Solutions Embraced by Children’s Dental Services • Portable, site-based care, particularly in school settings • Supporting dental clinicians to practice “at top of their licenses” • Utilization of mid-level providers such as Advanced Dental Therapist (ADT) • Use of telehealth (teledentistry)
Portable Dental Care Program Enables full range of care to be provided on-site in community- and school- based settings Equipment small enough to fit nearly anywhere Ideal for telehealth settings
HRSA Grant 16-012 Minnesota Rural Teledentistry Network Teledentistry Network Sites Grant period: 9/1/2016 – 8/31/2020 Aitkin County Health and Human Services Objectives: Carlton County Public Health and Human Services CDS will expand a telehealth network Chisholm Independent School District #695 Ely School District #696 across rural Minnesota, linking SBHCs, Head Starts and community public health Eveleth Gilbert Independent School District #2154 entities at 17 sites in underserved International Falls School District #361 Lakes and Pines Community Action Council counties. Little Fork-Big Falls School District #362 Meeker County Social Services Department Anticipated Outcomes: Mesabi East School District Children and pregnant women (2,000 in Mountain Iron-Buhl Public Schools #712 Princeton Public Schools #477 year 1 and 3,000 each in years 2-4) annually will have improved access to South Koochiching-Rainy River School District #363 ongoing care and improved oral and Southwestern Minnesota Opportunity Council overall health. St. Louis County Schools #2142 Virginia School District #706 Western Community Action
Need for Teledentistry 14 33 million Americans live in dental Counties: deserts DHPSAs DHPSA – Dental Health Provider Shortage Area 61% of MN counties are designated as DHPSAs 17 Rural MN Counties 1 County: 2 Counties: 3,903 Partial residents DHPSAs per dentist
Teledentistry Utilization and Effectiveness • Remote provision of dental care/advice using information technology rather than direct contact with patient • Accomplished via telecommunication technology, digital imaging and the Internet • Supported by Minnesota Department of Health (MDH) and Health Resources & Services Administration (HRSA) funding Decreases Provides care Results number of Reduces in comparable to appointments patient travel underserved in-person needed to areas treatment complete care
Minnesota Telehealth Legislation 2017 Minnesota Statutes 256B.0625 COVERED SERVICES Subd. 3b.Telemedicine services. (a) Medical assistance covers medically necessary services and consultations delivered by a licensed health care provider via telemedicine in the same manner as if the service or consultation was delivered in person. Coverage is limited to three telemedicine services per enrollee per calendar week. Telemedicine services shall be paid at the full allowable rate.
Teledentistry Protocol Hygiene services (including x-rays and patient assessments) provided at Rural Site A Providers at CDS headquarters in Minneapolis review x-rays and treatment plan On-site exam services no longer required at Rural Site A Restorative services provided at Rural Site A
Essential Equipment Laptop or Tablet with High-Definition Screen Affordable and accessible Light-weight, rugged, highly-transportable Allows Dental Charting and Data Entry to be saved and reviewed instantaneously Dell Latitude E6410 laptop $292
Essential Equipment Portable X-ray and Digital Sensors Small pieces of equipment which take high-quality dental radiographic images Allows clinician to stay by patient’s side while taking films Reduce radiation exposure by up to 60% when compared to exposure from film-based radiography (per American Dental Association) Images are instantly processed and saved to the patient’s file NOMAD Pro Digital X-ray System $6,400 GENDEX GXS-700 Digital Sensor $4,000
Essential Equipment USB Intraoral Camera Used to obtain images of the inside of the patient’s mouth, including soft tissue and chewing surfaces, which are unable to be captured via x-rays Photos are a superior tool for patient education and consultation on various treatment options Images are clear and magnified Sometimes a child is too young to tolerate x-rays but will allow intraoral photos to be taken GENDEX GX C-300 Intraoral Camera $1,410
Essential Equipment Dental Software CDS utilizes the Open Dental software program Compliant with federal Electronic Health Record (EHR) and HIPAA requirements Highly secure, providing virus protection, data encryption, and tamper resistance Allows providers to send and receive information (records, radiographs, intraoral photos) instantaneously, safely, and in an environmentally-friendly way Provides a variety of applications for practice and patient management Open Dental XVWeb Software $175 monthly plus additional fees per location and workstation
Essential Equipment Wi-Fi Hotspot Allows Teledentistry system connectivity in remote regions Overcomes fire walls present in community locations More secure than using host-site security connection, enhances privacy protection Easy to transport and cost effective
Dentists and Advanced Dental Therapists • Review clinical data, radiographs, photos, and observations from clinicians • Communicate with patients and families remotely • Plan and provide follow-up treatment
Exam Types Comprehensive exam (Dentist) – visual inspection of mouth and x-rays coupled with probe of each tooth’s surface, compared with dental and medical history Limited exam (ADT) – visual inspection of mouth and x-rays coupled with probe of each tooth’s surface Assessment (Hygienist) – visual inspection of mouth for noticeable decay
Aver erag age e Tim ime e to F o Fol ollo low-up up Car are Random Sample of 500 patients 250 received telehealth 250 received in-person exams * Number of patients requiring follow-up care is similar for both telehealth and in-person exams Dentist following conventional exam: 3.2 weeks Dentist following telehealth exam: 2.4 weeks Dental Therapist following conventional exam: 1.8 weeks Dental therapist following telehealth exam .8 week
Exam Completion Costs 52 exams Dentist Hygienist ADT $80/hour $27/hour $50/hour Complete exams OR Take x-rays, send to Complete exams OR read x-rays ADT/Dentist read x-rays 32 dentist hours to complete 52 conventional exams 32 hygienist hours plus 15 hours dentist hours to complete 52 telehealth exams
Cost Analysis of Teledentistry Exams by Provider Dentist (DDS) completes in-person exams • $80 x 32 = $2,560; $2,560/52 = $50.96/exam Hygienist completes assessment (telehealth), dentist analyzes/creates treatment plan • ($27 x 32) + ($80 x 15) = $2,064; $2,064/52 = $39.69/exam Hygienist completes assessment (telehealth), ADT analyzes/creates treatment plan • ($27 x 32) + ($50 x 15) = $1,614; $1,614/52 = $31.04/exam ADT completes in-person exams • $50 x 32 = $1,600; $1,600/52 = $30.77 Telehealth exam conducted by DDS: $11.27 savings/exam x 10,000 rural patients=$112,700 Telehealth exam conducted by ADT: $.27 savings/exam x 10,000=$2,700
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