Boston Group March 15, 2010

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1 Boston Group March 15, 2010 The Boston Group met on March 15 th. The attendees at this meeting were leaders of the Dental Associations from California, Connecticut, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, Oregon, Rhode Island, Vermont, and Washington. This group was formed as an information sharing forum for those states that were experiencing workforce activities proposed by legislators and other groups outside of dentistry. The group was formed specifically to share experiences and lessons learned and is not a policy-making group. As such, the group heard from the various states on the status of workforce in their states and their respective approaches. While most states had some minor activity, Connecticut, Minnesota, and Washington were able to share some important details about their particular situations. The lessons learned from these states will help other states counter any misperceptions and be proactive for dentistry earlier in the process. Presentations: National Update, Bill Zepp, Oregon Dental Association Josiah Macy Jr. and W.K. Kellogg Grant to AAPH, Allan Formicola, DDS, MS, Columbia University, Center for Family and Community Medicine CODA Task Force, Bryan Edgar, DDS, CODA chair Update on California s research agenda, Jon Roth, California Dental Association State by State Summaries: Connecticut Connecticut has had an activist hygienist in the legislature since 1992 who has been interested in expanding the dental workforce. Rejecting the Advanced Dental Hygiene Practitioner (ADHP) model as not viable, the Connecticut State Dental Association (CSDA) proposed the concept of developing a pilot project to test the efficacy of using a Dental Therapist (DT) model to improve access to care in the state. It passed their House of Delegates by a vote of 2 to1. A hygiene sponsored program was introduced this year. CDA has countered with their DT pilot project. Hygienists attempted to start an ADHP scope review process. CSDA asked that it be broadened to all dental workforce. Session died with no action taken. Lessons learned: Be an Advocate for the Poor: Because the hygiene proposal was not viable focusing only on the target, lowincome population, it was not narrowly tailored to serve this population. Hygiene stated in committee their bill was about creating a career path and not about access. The Connecticut Dental Association sponsored pilot project

2 focused on the target population making their proposal more attractive to the legislature. Increased Participation in Medicaid: Connecticut had just won an administrative rates lawsuit which lead to increased provider participation (they went from 150 DDSs participating in their program to 1,000 in 12 months). They also had a successful Mission of Mercy program with significant legislative participation. (2,049 patients seen). These activities helped the legislature understand how dentists are responding to the need for care. Minnesota Minnesota reported that everything about their process was available in their paper A History of Minnesota s Dental Therapist Legislation, Or What the Heck Happened Up There? In 2006, organized hygiene partnered with a local community college and a state university to advance the ADHP model. Faculty developed the educational program which was approved by the Board of Directors of the University system. In 2008, an ADHP proposal was introduced into legislation. Minnesota Dental Association was able to defeat the ADHP proposal, but the final bill that passed mandated the Board of Dentistry and the Minnesota Department of Health to constitute a workgroup to create the educational and licensure requirements for an Oral Health Practitioner (OHP). In 2009 two bills were introduced, one reflecting the ADHP-like model recommended by the OHP Work Group and the other reflecting the model developed by the University of Minnesota School of Dentistry. Subsequent negotiations produced two levels of the new practitioner, the Dental Therapist (DT) and the Advanced Dental Therapist (ADT). In 2008, the University of Minnesota School of Dentistry announced its proposed dental therapy program. Current Status of their program: DT and ADT models: The Board of dentistry is working on a process for approving dental therapist educational programs as well as licensure requirements, clinical and written examinations, and collaborative management agreement requirements. There are some sequencing issues with ADT requirements that are still to be resolved. 50% of DT/ADT patients must be underserved. This population represents either public program patients or others with with up to 200% of FPL. ADTs are required to have a collaborative management agreement with a dentist. There will be clinical testing following graduation of the program. There is not a proscribed salary range. They do not have an economic analysis, but plan to do one when the program is operational. There are two operational educational programs: University of Minnesota:

3 1 bachelor student and 8 masters students Being taught as part of the dental team side by side with dental students Program will cost $40,000. The school funded start-up costs from internal resources Metropolitan State University/Normandale Community College 7 Masters level students Being taught side by side with nursing students. Washington Legislative activity began when the Chair of their health committee wanted to create a dental nurse position. They anticipate that 2011 is when they will see a bill introduced in the legislature. Gauging Membership Attitudes: Washington formed a committee to study the issue, which originally recommended a DT model. WSDA officers and staff visited components (17) and received feedback on the proposed model. Membership not comfortable with with a 2 year training program for what was perceived as students right out of high school. Their membership felt like they were reinventing the wheel. Washington noted that it has had expanded function hygienists who are trained to place and carve restorations for 30 years and members preferred to build any new model off this. Same function was included in new (2008) Expanded Function assistant scope New Proposal for discussion: Washington has proposed a new model - for discussion only- now called the dental hygienist-therapist. Education is three years (one year of dental therapy following dental hygiene school. No bachelor s degree required). The practice setting is public health facilities as defined in Washington law (FQHCs, tribal clinics, nursing homes, hospitals, state institutions). There is no restriction on patient population, although it is targeted to low-income, Medicaid. WSDA proposal would require WREB clinical exam. Washington has a Larger Access Package: Washington s committee adopted a broader access package including early childhood education, increased funding for Medicaid, more dental sealant programs and more increase in charitable programs. They also plan to lobby the legislature on the importance of the oral health infrastructure if any new workforce model is to succeed. Washington is one of the five states (Kansas, Vermont, New Mexico and Ohio are the others) targeted by the Kellogg Foundation for a therapist proposal

4 Other State Activities: California There has been no significant state activity. PEW has made contact with local activists. There is no proposal pending at this time. California access problem is significant. With 36 million residents, approximately 10 million do not access care. California has begun doing research. Their Policy Development Council has appointed an Access Work Group and a Workforce Taskforce that are focusing on solutions that will specifically target these identified underserved populations. These committees have commissioned a number of reports to study many of the issues surrounding new provider models. Progress will be reported to their House of Delegates in November. Maine ADHP model introduced by organized hygiene last year. Organized dentistry proposed a Pediatric Therapist, which would be limited to treating children and only under the Direct supervision of a dentist. Speaker of the house asked both groups to not take up their proposal this year, so neither concept made it to a printed bill status. Maine anticipates workforce activity in the legislature next year. Lessons learned: Lack of adult dental program used against them Maine has not had an adult dental program except for emergency services for some time. A study on emergency room use, conducted by a major foundation in the state, will likely be used to argue for the need for a mid-level provider. Massachusetts Massachusetts recently expanded the duties of assistants and think this may be a reason they have not seen significant workforce activity. Hygiene has introduced a bill that would allow hygienists to work in underserved areas in public health settings and FQHCs. They could bill Medicaid directly, but must have a collaborative agreement with a dentist. The dentist does not need to be on site. Efforts by Dentistry to Address Access Built Good Will. Massachusetts support of expanded duties for assistants and efforts to expand the number of providers seeing Medicaid patients has built good will with legislators. Missouri

5 There are no active workforce discussions. Have been working on dental infrastructure. Missouri has also increased Medicaid funding the last few years; is beginning the American Academy of Pediatric Dentistry/Head Start Dental home initiative this year; and has received funding from the Missouri Foundation for Health to enhance their EFDA program. Legislation is being proposed by the Division of Professional Registration, Missouri Dental Board to permit EFDA s. Once this is accomplished the MDA and Missouri Dental Board will work to move forward rule changes that would allow EFDAs to place and carve all restorations. Difficult To Find One Voice. The Association is hearing from a variety of voices on the workforce issues within their membership. They anticipate a dental workforce bill may be introduced next year and are concerned how they will be able to respond without a single voice. New Hampshire No significant workforce activity at this time. New Hampshire had an ADHP bill introduced, and it became a study bill. The study was due this year but it has been extended for one more year. New Hampshire has worked with their local health Foundation to get data on access problem, especially for children. For the immediate future NH will focus their access solutions on those areas. They have developed a plan (Something to Smile About for 2010 and Beyond). Also, NH has a school based hygiene program and the NH Dental Society has met with them to determine their needs. Right now, the main focus of organized hygiene in New Hampshire appears to be self regulation. Oregon State of Oregon was awarded a HRSA grant (3 years) to set up pilot programs in three major areas of the state. These programs are training physicians to work with pregnant women with the goal of getting their infants into a dental home by age 1. This effort is being coordinated with Head Start. With regard to the dental workforce, organized hygiene introduced a bill to allow hygienists to administer anesthesia without supervision, but the bill failed passage in their session. Member Education is Key. This February, Oregon invited every dentist in the state to a meeting to discuss workforce. 4% of their members showed up, representing 14 of 17 components. Oregon provided their members with background on workforce activities, and then broke them into small groups and provided them with four scenarios. The groups were asked to recommend solutions to access and workforce issues.

6 Rhode Island No significant state activity at this time. Vermont Kellogg is working with Voices for Vermont Children, a very influential organization in Vermont, on a dental workforce proposal. Voices is forming their leadership committee. In a presentation to Vermont Head Start Voices has said that it would serve both children and adults, particularly adults in homes for the elderly and for people with disabilities. Voices was asked at this statewide Head Start meeting about their involvement with the dental society and were told that the dental society was not welcome on their committee. Subsequently and primarily due to the exclusion of the profession of dentistry, Head Start and the Vermont Public Health Association groups opted not to join the Voices leadership committee. Relationships with Other Organizations Are Important Vermont s relationship with Head Start and Public Health has created an opportunity to forge partnerships so that organized dentistry s voice can be heard. Other Reports: In addition to the individual state reports, the group heard about national workforce efforts including information about the national health reform proposal, foundation activity (Kellogg and PEW), IOM research and academic efforts to create a model curriculum. The group was pleased to note that the Austin Group was recently formed with the same desire to share information in the absence of a national dialogue. ADA, which has been virtually absent from the debate as a result of a HOD resolution, has offered to connect the two groups so that the information sharing could be more comprehensive. The Boston group asked that Washington, California and Oregon representatives contact ADA with a formal request to convene a National Issues Conference. A letter with that request, signed by all 12 state s presidents, has been send to Dr. Tankersley. At this point in time, the Boston Group has no scheduled follow-up meeting.

7 For review, below are brief summaries of the first two Boston meetings: The first meeting, held September 21-22, 2008 was attended by the sponsoring states of California, Oregon, and Washington, as well as Connecticut, Maine, Massachusetts, Minnesota, New Hampshire, Rhode Island, and Vermont. The meeting included the following: The group agreed that the gathering was an important opportunity for states facing workforce issues to have a forum where they could candidly share their concerns and seek input from colleagues facing similar circumstances. The group agreed the meeting would be limited to information-sharing, networking, and learning and would not develop policy recommendations or resolutions for the ADA. Overview of allowable duties in participating states for dental hygienists and dental assistants. There was quite a diverse range of duties allowed, highlighting that dental workforce changes will likely unfold with some variation depending on the state and its particular circumstances. Discussion of alternative providers in dentistry, such as the proposed ADHP and dental therapists, compared and contrasted with mid-level providers in medicine, such as physician assistants and nurse practitioners. Several concerns were expressed, including, whether a long educational pathway and the associated costs would allow a new provider to render care of similar quality to a dentist at a lower cost. Minnesota provided a legislative update on their evolving workforce category. States reported on dental workforce activity. Several states reported that they were facing the presentation of ADHP by their state Dental Hygiene Associations. The meeting concluded with agreement that it would be beneficial to meet again in 6-9 months for an update on progress in the several states. The second meeting, held March 29-30, 2009, was attended by the original states, as well as Missouri and New Mexico, who were also concerned about workforce activity in their states. The meeting included the following: Individual states reported on dental workforce activity, including an increased number of states facing proposals coming from outside of dentistry (legislatures, health advocates, etc.). Several presentations were provided to the group, including: o Review of the2009 Institute of Medicine workshop and the work of the Pew Charitable Trusts, Shelly Gehshan, Director, Advancing Children s Dental Health Initiatives, Pew Center on the States o Improving access to pediatric dental care through alternative dental providers, David Nash, DMD, MS, EdD, Professor of Pediatric Dentistry, University of Kentucky School of Dentistry o Overview of the Dental Health Aide Therapist, Louis Fiset, DDS, BA, DENTEX Curriculum Coordinator, University of Washington o Development of the Dental Therapist and Advanced Dental Therapist education and training in Minnesota, Patrick Lloyd, DDS, MS, Dean, University of Minnesota School of Dentistry o Integration of dental and nursing programs at NYU, Michael Alfano, DDS, Executive Vice Presidents, New York University, former dean, NYU School of Dentistry o Thoughts on the CODA approval process, James Koelbl, DDS, MS, MJ, Chair, Committee on Dental Accreditation, Dean, Western University College of Dental Medicine

8 The group discussed the days presentations and concluded with agreement that it would be beneficial to meet again in 6-9 months for an update on progress in the several states.

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