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Promising Practices: Dental Health at Choptank Community Health System | Streamline Winter 2016

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Last summer, migrant workers attending a mobile health clinic at their camps in Maryland received something new: an oral health kit, with a toothbrush, toothpaste, and floss. The kit, and the verbal and written information on oral health that accompany it, are part of Choptank Community Health System’s new dental service expansion into the migrant camps along the Eastern Shore of Maryland. Choptank, a Federally Qualified Health Center, has provided medical services at the camps for years -- but the integration of dental services into the scope of services offered is new.

“One of our hygienists will go out to the camp with the medical crew and do an exam to identify levels of decay as ‘priority one, two, and three,’ to see if there’s any active decay or infections,” in the mouths of the migrants who come to see a medical practitioner, says Shelley Andrews, Director of Community Based Programs and Marketing at Choptank. If needed, the practitioner providing medical care at the camp that day can prescribe antibiotics or other medications related to the screening on the spot, which are later brought to the camp. Based on the screening, the team can coordinate a daytime appointment at the dental office immediately if the need is high, or at an evening migrant clinic if it can wait.  

This expansion is in line with Choptank’s longtime focus on the integration of medical and dental care, which has led Choptank to expand from just one dental site in the early 2000s to dental services at four sites across three counties, at 30 schools through nine school-based centers, in addition to outreach and screening outside the dental offices. The health center is considering a dental services expansion using a full-service dental van that can provide basic dental services at the camps for migrant and seasonal workers.

Choptank turned to dental services provision for a simple reason: because their patients needed it. “For us, it was really based on the data,” explained Sandra Garbely-Kerkovich, DMD, Senior Vice President and Chief Dental Officer at Choptank. Statewide surveys found that children living on the Eastern Shore had a higher rate of dental disease than children in Baltimore City, an area often perceived as impoverished, which surprised the health center administration. Dr. Garbely attributes the discrepancy to a shortage of providers accepting medical assistance for dental care until recently, coupled with a lack of education on oral health within the pockets of extreme poverty on the Eastern Shore. “We wanted to think about how we can reach out and do these early interventions [and] identify the general disease,” before it required an emergency room visit or surgery, Dr. Garbely said. 

Choptank responded with a comprehensive dental care program for children, starting with those who are still teething, on up until they reach adulthood.  For the youngest children, they have partnered with their local Head Start to provide preventative services and conduct federally-mandated screening.  They also provide fluoride treatments for children under five years old in three Women, Infants, and Children (WIC) offices, an important preventative measure for migrant children who may miss out on fluoridated water if they rely on well water in worker housing in agricultural settings.  Dental Program Director Lorraine Loera noted that children have excellent dental coverage up to the age of 21 through Healthy Smiles Maryland, the statewide program for children, which covers a vast array of care including dental surgery if the dental team provides preauthorization.

Migrants of all ages also have good access to services.  Andrews noted that Choptank is particularly fortunate in that continuity of care is less of a concern with Eastern Shore migrants as it is in other parts of the country.  “In our service area, very few families come in as migrants,” she noted, as most are H2A or H2B visa holders, arriving solo to work as crab pickers or in local nurseries.  But the migrants who do come “have been coming here for 25 or more years.  They’re very established, and it’s easier to take care of their health issues because we’ve seen them for many years.”  She noted that many receive care in their home countries as well, and enjoy ongoing relationships with their practitioners when they return to Maryland.  She also pointed to the strong relationships that Choptank has built with many of the employers of the migrant workers, which allow them to coordinate on issues of night clinics and transportation. “We’re very lucky with the relationship that we have with our seasonal workers that come through and the people who employ them.  That allows us to provide better services to them. Familiarity really does help a lot.” 

Choptank further fills out its oral health program with multiple university partnerships.  “We have an active affiliation with the University of Maryland School of Dentistry in which we have dental students rotate on externship and also Dental Hygiene students rotate through our program,” Dr. Garbely explained.  “We also have a partnership with the Arizona School of Dentistry and Oral Health (ASDOH) in which each of our dentists has been credentialed and approved as external faculty and oversee the rotation of students on a five-week externship program.”

They also have a one- to two-year residency program through the New York University’s Lutheran Medical Center, plus a partnership with the local Chesapeake Community College for dental assisting students.  The load of extra personnel rotating in and out can be a challenge for scheduling, but Dr. Garbely believes the students bring new ideas and provide recruitment opportunities.

At Choptank, integration goes both ways. Dentists can access each patient’s complete electronic health record (EHR). If a patient has hypertension, “medical comes over and takes a blood pressure [reading].  If they’re diabetic, we ask them about it on this side,” at the dental office, said Dr. Garbely.  Barriers like transportation may make multiple office visits difficult, so coupling appointments to get a patient all the services needed on one day is a priority, and a huge advantage for a patient like a migrant worker who may not have a flexible schedule, said Andrews. 

Choptank’s dental services are tracked through quality and productivity measures, broken down by site and provider.  Choptank offers performance incentives related to their productivity measures. They track their no-show rate closely (see sidebar).  Choptank tracks dental-related quality measures including chart audits for accurate documentation and sealed chart notes, which are completed within 72 hours of patient care.  They are also succeeding on what Dr. Garbely calls their Dental Pillar goals.  In 2015, they reached their Dental Pillar goals of 75 percent of overall treatment plans completed and 50 percent of children ages six to nine who are recommended for preventative sealants receive those sealants. 

But their robust dental program isn’t just a response to the need in their community; it’s an outcome resulting from a fully dedicated staff, at all levels.  “There’s a passion here, and we go by our principles: we find the need, and we all collaborate.  Everybody talks to each other,” Dr. Garbely explained, including the executive team.  “You can’t do it without your Senior Management team and Board knowing what’s going on and being passionate about what you’re doing.  Our Senior Management team meets weekly and talks about all of our departments including dental.  Everybody’s got to be on board.”

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