Implementation of an Integrated Community-Based Dental Care System for Low Income Children: Initial Findings (Preprint)

BACKGROUND To improve access to care and reduce disparities in oral health of low-income children and pregnant women, this quality improvement program used expanded practice dental hygienists, provided an evidence-based risk assessment and dental caries management protocol-based care in community settings, and paid personnel based on performance. A health information technology system was implemented integrating community-based practice, case management, and clinic records. OBJECTIVE Our objective was to describe the first year of implementation of the program including the processes, services provided, and factors that helped and hindered these implementation efforts. METHODS The mobile integrated community-based delivery system (PREDICT) was implemented as a quality improvement project within a large Dental Care Organization (DCO) that includes fixed dental clinics and contracted practices. The program is being tested in a randomized controlled trial. The target populations were Medicaid-eligible children and pregnant women in 7 rural counties in Oregon State USA. Data were collected from staff and community surveys, interviews, and administrative and dental health records. RESULTS Baseline assessments indicated patient satisfaction with care and staff readiness to implement changes were high. In PREDICT counties 9 expanded practice dental hygienists provided 37,369 services - an average of 4,152 services per EPDH in 198 community sites. Utilization ranged from 33-63% of eligible children and 30-42% of women, respectively, by county. For patients with ≥1 visits, 42% received a needs assessment, 88% preventive services and 26% restorative or endodontic services. By dental care need levels, 34% were low, 30% moderate, 32% high and 4% were not assigned to a group. Among moderate-need group, 51% received 1 silver diamine fluoride application and 19% two applications. Within the high-need group referred to dental clinics, 11% had urgent needs, 56% non-urgent needs, and the remaining 33% had non-urgent needs that could be treated in community settings. About 51% of the high-need group referred to dental clinics received services. CONCLUSIONS Initial findings confirm the strong emphasis of the program on access and use of preventive services, and the varying degrees of program reach in different counties. Implementation challenges in communities at different stages of collaboration between the dental care, school, and other community organizations limited the achievement of the audacious goals of the program in its first year. CLINICALTRIAL ClinicalTrials.gov Identifier: NCT02312921