While maintaining good oral health is essential to overall health, ensuring access to dental and oral health services has long been challenging in the U.S., especially in medically underserved communities with multiple barriers to care. Health care systems continue to grapple with meeting the gaps in care, and integrating oral health care with general health services. Community health centers have heeded the call of the Office of the U.S. Surgeon General, “to change the perception of oral health as separate from medical health,” and have played a key role in developing and implementing models that help integrate oral health and primary care.
“Health centers are people-centered health homes, and to care for the whole person, you have to include the integration of oral and behavioral health.” In 2017, 81% of the nation’s community health centers offered dental care, and in all, provided 15.7 million dental visits, an increase of 70% since 2010. Don Weaver, M.D., Senior Advisor, Clinical Workforce at the National Association of Community Health Centers (NACHC) explains that “health centers are people-centered health homes, and to care for the whole person, you have to include the integration of oral and behavioral health.” We visited with a few colleagues whose organizations are dedicated to doing just that.
Community Health Center of Franklin County, Inc. (Greenfield, MA)
The Community Health Center of Franklin County (CHCFC) opened in 1997 in Turners Falls, Massachusetts, and today has three sites. CHCFC began offering dental services in 2001. Providing accessible points of care and integrated service in the largely rural community is the foundation of the CHCFC approach. In addition to offering comprehensive oral health and urgent dental walk-in care at its two main dental clinic sites, the center provides services at its Urgent Dental Clinic located inside the Baystate Franklin Medical Center. Dental Director Dr. Allison van der Velden explained “we’re in a rural area and we don’t have a lot of public transportation. So transportation really is a big barrier for people.” CHCFC recently relocated a medical and separate dental practice to a combined site in downtown Greenfield, located on an accessible bus route; CHCFC expects that this will make it much easier for people to make – and keep – their appointments.
A mobile, school-based dental hygiene program currently serves 19 schools and locations in the surrounding communities. This program offers essential early intervention, including cleaning, sealants, and fluoride applications to the area’s children. Recently, through a partnership with the Connecticut River Valley Farmworker Health Program, the health center began offering medical visits to agricultural workers and their families. Dr. Van der Velden hopes that dental visits will follow suit: “We’re really excited about that. It’s not that people don’t want to finish their treatment plans, but often they don’t have the resources or time to come back.”
“I can fix the holes in your teeth, but if we don't change something about the environment or find some way to decrease your risk for new cavities, then you’ll just be back.” Community partnerships, and an emphasis on understanding the needs of each patient, drive the practice. “I can fix the holes in your teeth, but if we don't change something about the environment or find some way to decrease your risk for new cavities, then you’ll just be back. I want my patients to be caring for their teeth and I’m here to help them find the best and most effective strategies.”
Piedmont Health Services, Inc. (Carrboro, NC) and North Carolina Community Health Center Association
Founded in 1970 as the Orange-Chatham Comprehensive Health Services, Piedmont Health was established by the University of North Carolina at Chapel Hill Division of Health Affairs and a local Community Action Plan to provide comprehensive healthcare services and education to all members of the community, and address gaps in access. Today, Piedmont Health operates 8 sites in 14 counties, and dental care is now offered at five sites, including a recently renovated site in Carrboro, and an expanded practice in Burlington. Comprehensive dental care is available to infants, children and adults of all ages. The Baby Oral Health Program (BOHP) serves infants through age 3. Through early detection and treatment including dental sealants, the health center helps children prevent and avoid tooth decay and dental problems later in life.
“As an organization, we work together and collaborate well together. It makes me happy to be an employee working together with our medical and WIC departments.” Lauria Davis, the health center’s Dental clinic manager and dental hygienist, stressed the relationship between oral health and general health and well-being. Good oral health needs to start early, and is essential at every age. That’s why the health center emphasizes close communication between the medical and dental teams, and interdepartmental referrals. “As an organization, we work together and collaborate well together. It makes me happy to be an employee working together with our medical and WIC departments.” Through community events like Give Kids a Smile the health center provides free dental screenings, exams and cleanings to children who do not have insurance.
“We want to make sure that people understand that you’re not going to have good diabetes control if your patients have rampant oral health issues.”Piedmont Health is committed to filling gaps in care and ensuring that each patient’s medical home includes the dental services needed for optimal health. Like other centers in the state, Piedmont’s efforts are supported by the work of the state’s primary care association, North Carolina Community Health Center Association. Marti Wolf, RN, MPH, the Association’s Clinical Programs Director, described their work to support the health centers that want to open or expand dental services. Ms. Wolf explained, “We’re trying to show how all these different pieces integrate and the impact of oral health on the body. We want to make sure that people understand that you’re not going to have good diabetes control if your patients have rampant oral health issues.” A quarterly dental directors' work group provides opportunities for colleagues to meet with dental directors' and learn from existing programs.
Providing comprehensive care takes trained, competent, dedicated professionals. Across the country, CHC dental care is provided by nearly 18,000 full-time equivalent staff, including Dental Hygienists (14%) Dentists (27%) and Dental Assistants, Aides, and Techs (59%) – but expanding care will require more trained professionals at every level. NCCHCA works with the University of North Carolina and East Carolina University School of Dental Medicine. By educating North Carolinians to become dentists, these students will return to their communities and health centers, achieving both training and access goals.
“A challenge for us is to have a workforce that represents the population we serve. We all need to work on diversifying our workforce.” Dr. Weaver added that it’s really important to “grow our own,” explaining that those best suited to serving a community have a deep personal commitment and understand the issues affecting the community through their own experience. “A challenge for us is to have a workforce that represents the population we serve. We all need to work on diversifying our workforce.”
To expand care in both urban and rural areas, partnerships are essential. NACHC works with a variety of partners, including the National Network for Oral Health Access, National Oral Health Innovation and Integration Network, Oral Health Progress and Equity Network (OPEN), and the National Health Service Corps to provide assistance and support to health centers in developing and strengthening their dental programs. It also partners with schools, including A. T. Still University’s Arizona School of Dental and Oral Health, Missouri School of Dental and Oral Health and NYU Langone.
Ellen Robinson, Clinical Affairs Director of Information Resources and Outreach at NACHC put it like this: “It's not just NACHC, it's a lot of partners helping us to reach our urban and rural health centers across the country.” Understanding local needs, and forging effective collaborations, is crucial to expanding the availability of high-quality oral health care.
Photo: Dental Staff, courtesy of Kinston Community Health Center Inc. (North Carolina).
-Irene Bruce, February 25, 2019