Abstract
The American Dental Association's Community Dental Health Coordinator program was designed to teach community health worker skills to dental auxiliaries. Case management, a valued skill utilized by medical providers, is largely unknown in the dental profession. When case management is incorporated into a dental professional's practice, prevention becomes amplified, leading to decreased costs and increased access.
Much attention has been paid to the value of community health workers who greatly assist underserved populations by “connecting” them to health care delivery systems. These navigated connections are effective due to the special skills of these workers who have training that helps individuals and communities overcome specific barriers to health care. Health literacy and education level are just 2 of the barriers identified within the category of social determinants [1]. Social determinants of health (SDH) have been defined as conditions that influence a person's health status, such as education, income, wealth, employment, and general living conditions. Additional considerations include access to quality food, walkable neighborhoods, and exposure to the arts [2].
Some social determinants have been identified as barriers because of their impact in health care decision making not only for individuals, but also for families. When it comes to oral health, which is often not included in discussions of primary care, additional barriers are in place. For example, lack of familiarity with dental appointment protocols and terminology make the connection between individuals and dental professionals that much harder.
While emerging science continues to stress a mouth-body connection for health status, typical conversations between patients and medical providers do not include a meaningful mention of the role of oral health in relation to overall health. The oral cavity remains a black box of unknown and often unexplored territory even to the most skilled medical practitioner. This unfortunate comfort level with the mouth being “detached” from the rest of the body may be due, in part, to the educational climate of many medical schools, where an average of 1 hour gets devoted to oral health during a 4-year medical school curriculum [3].
Many medical teams attempt to encourage patients to seek dental care but lack the foundational knowledge of what, how, or why specific dental services are necessary. With so much information to review for a particular patient, few medical professionals recognize the impact that a raging dental abscess or the chronic inflammation of periodontal disease could have on a pregnant woman or diabetic patient [4].
Many care coordination teams include valuable interdisciplinary members, such as pharmacists, social workers, or nurse clinicians, but when it comes to the mouth, not much gets said (pun intended) or done. And who could expect that to happen? Without a specific background in the relevance of oral health, who could advise a patient about necessary dental services, treatment protocols, clinical terminology, or appointment expectations?
It was for this reason that the American Dental Association (ADA) designed the Community Dental Health Coordinator (CDHC) curriculum. When incorporated within an existing training program for dental hygienists or dental assistants, a collection of community health worker skills are integrated into the dental realm, including case management and care coordination.
It may be helpful to define these 2 key terms. Case management is the consumer-centric collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and resources to promote cost-effective quality outcomes [5]. It can connect people with opportunities for care that they may not know exist. It also includes support for caregiving, while helping patients develop self-management strategies to enhance their abilities in problem solving. Care coordination is the concept of health care professionals working with patients to ensure that their health needs are being met and that the right person is delivering the right care at the right time. Communication pathways between patient care teams, organizations, and/or community services are included in this concept and considered part of case management.
In this 21st-century era of coordinated care, oral health services should be integrated into a patient's total health care plan via a CDHC. For patients who need special services, such as radiation oncology, the timing of dental services is critical and, for quality purposes, include more instruction than a suggestion of “go visit the dentist.” For those who are apprehensive about dentistry, much more case management and patient navigation are needed.
Other Community Dental Health Coordinator Skills
Motivational interviewing, cultural competence, and health literacy are some other focus areas of the CDHC program. Addressing the upstream determinants of poverty with cultural competency allows dental professionals to connect patients to dental care and provide details about appointments while increasing the patient's awareness of the importance of oral health.
Further, CDHCs may perform preventive dental services as allowed by a State Dental Practice Act, as well as perform community oral health promotion and outreach duties. They can instruct patients in how to enroll in various insurance programs while collaborating with community partners to connect patients with dental care sites, which have access but are underutilized.
Professional accountability becomes a visible part of this entire process, as a health care professional should not allow a patient's oral health status to become ignored or adversely impact the success of other aspects of their care. It is in these facets of patient management that CDHCs show their true value. Being able to assess and share a patient's oral health issues and comfort level allow for more effective scheduling, culturally competent translation of dental jargon, and successful anxiety management, which enhances appointment compliance.
Other specific competencies of a community health worker are also taught within the CDHC program. The online modules contain specific chapters addressing pertinent patient considerations, such as Social Determinants of Health, Community Diagnostics, Community Resource Mapping, Cultural Humility, and Verbal and Non-Verbal Communication, as well as various mechanisms of dental care financing. CDHCs are trained in enrollment processes of third party payer programs and receive in-depth training in client-centered counseling skills.
Another aspect of CDHC training is a section devoted to Health Literacy and the skill set associated with “OARS,” which is the practice of asking open ended questions, affirmation of what one has heard, reflective listening, and summary reflections. These basic interaction techniques add much to any health professional's repertoire.
Community Dental Health Coordinators in North Carolina
In the state of North Carolina, there are several ways that the CDHC program could increase oral health promotion and access to dental care. Both the ADA and the American Association of Pediatric Dentistry (AAPD) recommend that a child's first dental visit should take place by 1 year of age. By having a CDHC working within or periodically visiting a pediatric practice, oral health screenings and application of topical fluoride varnish could accompany well-child visits, and parental oral health education could be reinforced during the appointment.
CDHCs could assist North Carolina pediatricians and promote prevention of decay throughout the state. This amplification of medical-dental collaboration would have a significant impact in educating families and performing risk assessments for the most vulnerable and newest citizens.
Dr. Debra Best, Duke University educator, currently serves as the North Carolina Chapter Oral Health Advocate for the American Academy of Pediatrics. She takes every opportunity to leverage the message of oral health within the Patient Centered Medical Home (PCMH) model as defined by the Agency for Healthcare Research and Quality (AHRQ) [6].
What is one of the key criteria for a medical practice to become a PCMH? That would be care coordination, which would include an oral health component to be most efficient and effective. This integration of oral health within the PCMH model could significantly decrease the burden of disease and subsequent cost of childhood caries in North Carolina. According to the North Carolina Department of Health and Human Services, nearly 40% of all 5-year-olds have experienced tooth decay in their primary or baby teeth [7].
Another use for CDHCs in North Carolina would be to assist patients in accessing dental services in rural areas. The East Carolina University School of Dentistry has locations where student dentists work with health center dental departments to deliver patient care. Effective outreach in these areas could mean more predictable scheduling, more preventive services delivered, and more completed treatment plans. All these factors lead to reduced burden of disease and less recurrent disease.
CDHCs will be seen in North Carolina soon. Alamance Community College is the first school in the state that will offer the CDHC curriculum. The ADA will work with them throughout the implementation phase of launching this training program within their area of Graham and measure the impact of the students' work in the community as they move through the training.
The ADA provides ongoing technical assistance for schools offering the CDHC curriculum. Schools may offer the program as a Continuing Education Series or as “stacked” credits within their already existing dental training curriculum. Currently, there are over 110 graduates of the program with another 130 individuals in the educational pipeline. The graduates and trainees of the program have expressed interest in branding with a visual infographic explaining the work of CDHCs while offering key aspects of the program's focus. See Figure 1 for the recently approved program symbol.
Community Dental Health Coordinators Overview
There are now 16 educational institutions engaged with the CDHC curriculum, and there are others preparing to offer the program in 40 out of 50 states. This new skill set for dental professionals provides a stronger case for connecting the mouth with the rest of the body. By making oral health services more patient centered, the integration of dental and medical worlds has a greater probability for improved quality, lower costs, reduced disease, and healthier populations. Isn't that a goal worthy of North Carolina?
Acknowledgments
Potential conflicts of interest. J.G. has no relevant conflicts of interest.
- ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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