Dental Clinics. brian k. shue, dds, and huong le, dds

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1 health ceters cda joural, vol 37, º 5 The Framework for Patiet Care at Califoria Commuity Health Ceter Detal Cliics bria k. shue, dds, ad huog le, dds abstract Commuity health ceters i the Uited States improve access to detal care for uderserved populatios ad idividuals who live i uderserved areas. The ot-for- profit health ceters provide care to patiets regardless of their ability to pay ad must follow extesive federal ad state regulatios. There are 245 Califoria health ceter sites that provide detal care. This article reviews the framework for patiet care at the Califoria commuity health ceter detal cliic. authors Bria K. Shue, dds, is the detal director at Cliicas de Salud del Pueblo Ic. i Imperial Couty, Calif., ad a associate editor for the Joural of the Califoria Detal Associatio. Huog Le, dds, is the detal director at Asia Health Services Commuity Health Ceter i Oaklad. For more tha 40 years, commuity health ceters i the Uited States have provided comprehesive health care to uderserved populatios ad patiets i uderserved areas regardless of their ability to pay. Authorizig legislatio has officially chaged the term commuity health ceter to the accepted term health ceter. 1 The Health Resources ad Services Admiistratio, HRSA, of the U.S. Departmet of Health ad Huma Services recogizes the health ceter (HC) as a all-ecompassig desigatio that icludes the followig: federally qualified health ceters, FQHC, FQHC look-alikes, outpatiet health program/facility operated by tribal orgaizatios, hospital-based or detal school-based programs, commuity public health departmets or others 2 (table 1). All of these listed etities are kow as safety et providers because they provide health care to uderserved patiets regardless of their ability to pay. FQHCs are ot-for-profit orgaizatios that receive grat fudig uder the Health Care Program, Sectio 330 of the Public Health Service Act. 3 FQHCs are commuity health ceters, migrat health ceters, health care for the homeless programs ad public housig primary care programs. 2 HRSA states that health ceters provide services to the medically uderserved or to a special medically uderserved group of migrat ad seasoal agricultural workers, the homeless, ad residets of public housig. 3 The Califoria Primary Care Associatio describes additioal users of health ceters as those with laguage or cultural barriers, those with fear of repercussios o immigratio status, ad those who are may

2 health ceters cda joural, vol 37, º 5 table 1 Glossary of Key Terms CHC Commuity health ceter, also ow simply referred by federal regulatios as health ceter. Health Ceter All-ecompassig term. Meas a etity that serves a populatio that is medically uderserved, or a special medically uderserved populatio comprised of migratory ad seasoal agricultural workers, the homeless, ad residets of public housig, by providig, either through the staff ad supportig resources of the ceter or through cotracts or cooperative arragemets HRSA. A health ceter ca have ay of the followig i its orgaizatioal system: commuity health ceter, migrat health ceter, health care for the homeless, school-based, or public housig primary care. Safety Net Provider All commuity health ceters, local couty health departmets, public hospitals ad other health care providers who provide health services to the uderserved populatios, regardless of their ability to pay. FQHC Federally qualified health ceter, a ot-for-profit health ceter orgaizatio with oe or more cliic sites ad receives Sectio 330 federal grat support uder the U.S. Public Health Service Act to provide health services to uderserved populatios. Uses a slidig fee for eligible patiets. There are 376 FQHC sites i Califoria, as of FQHC Look-Alike A health ceter that meets all requiremets to be a FQHC but does ot receive ay Sectio 330 federal grat support. There are 71 FQHC look-alike sites i Califoria, as of Federally qualified health ceters that receive federal grat fudig uder the Health Ceter Program, Sectio 330 of the Public Health Service Act. There are 110 Sectio 330 gratee orgaizatios i Califoria, as of Slidig Fee FQHCs ad FQHC look-alikes provide access to services without regard for a perso s ability to pay ad provide a slidig fee discout. This discout is based o the patiet s ability to pay, usig the patiet s aual icome ad family size accordig to the most recet U.S. Departmet of Health & Huma Services Federal Poverty Guidelies HRSA. UDS Uiform Data System. Federal system tracks a core set of iformatio appropriate for reviewig the operatio ad performace of health ceters, icludig patiet demographics, services provided, staffig, cliical idicators, utilizatio rates, costs, ad reveues. UDS data are collected at the gratee, state, ad atioal levels. Medi-Cal Califoria calls its Medicaid program Medi-Cal. It provides health coverage for low-icome people ad people with disabilities ad is fuded by federal ad state moies. CMSP The couty medical services program provides health coverage for low-icome, idiget adults i 34 primarily rural Califoria couties, maaged by the CMSP Goverig Board admiistered by Athem Blue Cross Life & Health Isurace Compay. CMSP is ot Medi-Cal. HPSA A health professioal shortage area is a geographic area, populatio group, or medical facility that has bee desigated by the Secretary of the Departmet of Health ad Huma Services as havig a shortage of health professioals ad is assiged a score based o the level of eed. ot able to use traditioal health services. 4 HCs i the Uited States provide comprehesive ad culturally competet services to the uisured ad a growig miority populatio, ad are a valuable asset i reducig emergecy room admissios, accordig to the Natioal Associatio of Commuity Health Ceters. 5 I fact, HCs have bee reported to be oe of the federal govermet s most successful programs by the Office of Maagemet ad Budget. 6 There are may agecies ad support orgaizatios for the HC (table 2). Residets i Califoria face may challeges (table 3). Because of the icreasig cost of health isurace, HCs will cotiue to be a importat model to serve Califoria s uisured. 7 Califoria has 6.5 millio uisured residets, which is almost oe i every five residets, ad is 15 percet of the uisured populatio i the Uited States, the largest total of ay state. 8 To meet the eeds of the high umber 320 may 2009

3 cda joural, vol 37, º 5 table 2 Agecies ad Support Orgaizatios for the HC HRSA/BPHC Health Resources ad Services Admiistratio HRSA, a agecy of the U.S. Departmet of Health ad Huma Services, is the primary federal agecy for improvig access to health care services for people who are uisured, isolated, or medically vulerable. It is made up of six bureaus, icludig the Bureau of Primary Health Care, BPHC. HRSA provides leadership ad fiacial support to health care providers i every state ad U.S. territory. HRSA gratees provide health care to uisured people, people livig with HIV/AIDS, ad pregat wome, mothers, ad childre. They trai health professioals ad improve systems of care i rural commuities. hrsa.gov ad bphc.hrsa.gov. Accessed March 3, DHCS Departmet of Health Care Services DHCS is a departmet withi the Califoria Health ad Huma Services Agecy. DHCS missio is to preserve ad improve the health status of all Califorias. DHCS works closely with health care professioals, couty govermets ad health plas to provide a health care safety et for Califoria s low-icome ad persos with disabilities. dhcs.ca.gov. Accessed March 3, CPCA Califoria Primary Care Associatio Membership orgaizatio of more tha 645 commuity cliics ad health ceters, CCHC, sites ad regioal cosortia. CPCA is charged with the missio of stregtheig its member CCHCs ad etworks through advocacy, educatio, ad services i order to improve the health status of their commuities. Through its work with member orgaizatios, CPCA accomplishes its missio, visio, ad core values by promotig ad advocatig for equal access to high quality health care for all Califorias. cpca.org. Accessed March 3, NACHC Natioal Associatio of Commuity Health Ceters The oly atioal orgaizatio dedicated exclusively to expadig health care access for America s medically uderserved through the commuitybased health ceter model. Works with a etwork of state health ceter ad primary care orgaizatios to serve health ceters i a variety of ways. achc.org. Accessed March 3, NNOHA Natioal Network for Oral Health Access NNOHA is a atiowide etwork of detal providers who care for patiets i migrat, homeless, ad commuity health ceters. These providers uderstad that oral disease ca affect a perso s speech, appearace, health, ad quality of life ad that iadequate access to oral health services is a sigificat problem for low-icome idividuals. The members of NNOHA are committed to improvig the overall health of the coutry s uderserved idividuals through icreased access to oral health services. The NNOHA Web site is a collectio of iformatio, cotacts, ad resources for curret ad prospective members. oha.org. Accessed March 3, CHCF Califoria HealthCare Foudatio The Califoria HealthCare Foudatio is a idepedet philathropy committed to improvig the way health care is delivered ad fiaced i Califoria. By promotig iovatios i care ad broader access to iformatio, our goal is to esure that all Califorias ca get the care they eed, whe they eed it, at a price they ca afford. chcf.org. Accessed March 3, Deti-Cal seek detal care ad, furthermore, less tha 2 percet of this group receive detal care at Califoria HCs. 12 HCs that provide direct detal care are able to provide comprehesive services for its patiets similar to what is available to patiets i the private sector. The latest data shows that out of the 857 total licesed commuity cliic sites, oly 245 Califoria HC sites provide direct detal care, just 29 percet of the sites. 12 For the purposes of this article, the term CHC will be used as it is the specific type of health ceter that will be discussed (table 1). This article will focus o the framework of providig detal care to the uderserved at the ot-for-profit comof uisured residets, 323 ew Califoria HC cliic sites opeed their doors from 1995 to 2005, a icrease of 68.6 percet, ad all Califoria HCs took care of over 3.6 millio patiets i more tha 11 millio patiet ecouter visits i both rural ad urba commuities i As of 2007, there are 110 Sectio 330 FQHC corporatios or orgaizatios i Califoria. 9 The missio of the HCs make them a valuable part of addressig access to detal care. 10 Califoria has 8.5 millio poor, elderly, ad disabled patiets eligible for the state Medicaid detal program, kow as the Deti-Cal program. 11 HCs are well-prepared to take care of Deti- Cal patiets. However, it is oted that oly 26 percet of those eligible for muity health ceters i Califoria ad will cover the followig subjects: licesure ad basic services, the CHC detal cliic, admiistratio, detal director, staff detist, patiet care o types of coverage ad scope of service, ad quality assurace. Licesure ad Basic Services HCs provide comprehesive health care to may differet types of people ad areas of eed (table 4). The Califoria Departmet of Public Health, CDPH, defies the commuity cliic as a cliic operated by a tax-exempt oprofit corporatio that is supported ad maitaied i whole or i part by doatios, bequests, gifts, grats, govermet fuds or cotributios that may be i the may

4 health ceters cda joural, vol 37, º 5 table 3 Facts of Life i Califoria 794 health ceter cliic sites (2005 CPCA data) form of moey, goods, or services. I a commuity cliic, ay charges to the patiet shall be based o the patiets ability to pay, utilizig a slidig scale, pursuat to Sectio 1204 (a)(1)(a) of the Health ad Safety (H&S) Code. 13 A CHC must also satisfy the followig requiremets set by HRSA: be located i or serve a high-eed commuity, be govered by a commuity board, provide comprehesive primary health care services as well as support services, provide services to all residets regardless of ability to pay, establish a slidig fee schedule based o icome, ad meet other performace requiremets. 2,5 All CHCs must also completely follow Califoria code of regulatios called Title 22, which provide detailed istructios divided i the followig categories: licese, basic services, drug distributio, admiistratio, ad physical plat. 14 All applicable laws ad regulatios of Califoria, icludig that of the Califoria Detal Board, apply to the private detal office also apply to the CHC. Yet, to esure the appropriateess of care ad the safety of the patiet populatio served, HRSA, Title 22 ad other regulatios require compliace through routie CHC ispectios ad audits from the federal, state, ad local levels that are ot always foud i the private sector. This oversight starts with a CDPH licesig ad certificatio officer ispectio i order to receive licesure to operate. For , the CDPH basic licesig fee for a CHC is $600 aually per each site. 15 Other idividual liceses are required for the detist ad licesed persoel, just as with a private detal office. As per Title 22, the CHC must provide writte documets available for review o basic services. I order to esure comprehesive care, geeral requiremets state all patiets of record will have diagostic, therapeutic, radiological, 110 overall Sectio 330 gratees gratee ca have oe or more compoet(s) 93 Sectio 330 gratees with a CHC compoet 26 Sectio 330 gratees with a Migrat Health Ceter compoet 25 Sectio 330 gratees with a Health Care for the Homeless compoet 7 Sectio 330 gratees with a School-based compoet 7 Sectio 330 gratees with a Public Housig Primary Care compoet 2007 UDS data 6.5 millio are uisured (1 i 5 Califorias) 3.6 millio patiets receive care at HCs with more tha 11 millio ecouters Nearly two-thirds of cliic patiets (62 percet) have icomes below the federal poverty lie; 83 percet live below 200 percet of poverty Raks 47th out of 50 states i total Medi-Cal (Medicaid) spedig per beeficiaries ad speds the least o beeficiaries amog the 10 most populous states Califoria health ceters still oly received $199 (federal dollars) per uisured patiet served, which is sigificatly less tha the atioal average of $309 per uisured patiet ad less tha other states with large uisured populatios such as New Mexico ($362) ad Texas ($247). Califoria s huge uisured commuity cotiues to make the case for 330 fudig icreases. The average total aual cost of care: for Medi-Cal patiets at HCs: $455 for Medi-Cal patiets at office-based medical providers: $657 HCs reduced Medicaid spedig by 30 percet Health ceters overall ecoomic impact of more tha $3.15 billio i 2005: directly ijectig almost $1.6 billio ito their local ecoomies ad supportig more tha 26,500 jobs (13,953 full-time jobs directly ad idirectly supportig aother 12,254 full-time jobs through their operatig expeditures). Source: Califoria Primary Care Associatio. laboratory, ad other services provided at the cliic or have a system of referrals to other providers. The cliics must have a licesed professioal to supervise the provisio of each service, writte care policies ad referece materials, ad proper equipmet to provide services. The basic policies ad procedures for a CHC required by Title 22 iclude the type of cliic ad scope of services to be provided to its patiets, patiet care, educatio of the patiets, plas for follow-up, referrals, hadlig emergecies, available emergecy cosultatio, ursig procedures if provided, ifectio cotrol, treatmet of miors or those uder guardiaship, ad opportuities for couselig. If CHCs provide detal services, it falls uder the auspices of the medical departmet. The CHC must have a licesed physicia appoited as the professioal director, kow as the medical director, who is resposible for all services provided. I cases where o medical services are give, the the professioal director is the detist. The medical director oversees policies ad stadards, quality, protocols, peer review, credetialig ad assigig cliical privileges, ad esurig at least oe member of the staff has hospital privileges may 2009

5 cda joural, vol 37, º 5 table 4 Patiet Profile of the Califoria Health Ceter 70 percet are from ethic commuities 49 percet report Eglish as the secodary laguage 35 percet are childre uder 19 years of age, as of 2004 About 70 percet of adult wome 4 percet are seiors Source: Califoria Primary Care Associatio. The CHC Detal Cliic Califoria regulatios establish basic physical requiremets for the detal cliic. It requires the cliic to operate i a clea ad completely fuctioal eviromet. The requiremets listed i Title 22 do ot differ greatly from basic expectatios for a private facility or detal office. Thus, there is usually o geeral differece i appearace ad fuctio of a CHC detal cliic compared to ay other detal office. For example, proper stadard precautios ad ifectio cotrol regulatios set by the Califoria Detal Board must be followed i both types of offices. There are some additioal requiremets set by Title 22 for patiet safety. For example, all autoclaved bags should be marked with expiratio dates. Other examples of differeces iclude such basic CHC requiremets as havig flashlights maitaied ad ready for use at ay time, a miimum requiremet that all equipmet must be tested ad calibrated aually with documetatio available, ad quarterly bacteriological aalysis of water at the cliic to esure patiet safety. Some CHCs use mobile vas to reach out to their patiets: Urba CHCs have utilized mobile cliics to go to school sites to provide the eeded medical or detal care, ad rural cliics have used mobile vas to deliver care at migrat camps, remote locatios or school programs. Detal mobile vas ca be completely self-cotaied with oe or two fully fuctioal, albeit smaller, operatories, a waitig area, a restroom for staff ad patiets, ad a sterilizig area. Vas ca be a recreatioal vehicle, platform, or o a trailer bed that eeds to be pulled to each locatio. The Califoria Detal Practice Act ow allows mobile detal cliics to be licesed ad owed by the CHC istead of the detist. Although most of the mobile cliics are limited to school-based Head Start programs, several of these cliics reach out to the special populatios such as migrats, homeless, ad patiets with HIV/AIDS. The mobile cliic operatios have prove to be quite challegig the califoria Detal Practice Act ow allows mobile detal cliics to be licesed ad owed by the CHC istead of the detist. ad could be a fiacial drai for health ceters. These challeges iclude the logistics to brigig the va ad staff to remote locatios, trasiet patiets, eed for specialized staffig like the mobile va driver, ad the costs of maiteace ad repair. Of special cocer is the cost of fuel, especially whe gasolie had sold at more tha $4 per gallo i Sice RVs get less tha 5 miles per gallo, it ca be quite costly to fill a 75-gallo tak. Additioally, vas equipped with gas-powered geerators (or diesel) to ru the operatories will steadily draw (or drai) fuel from the tak uless the va is plugged ito a electrical grid. Admiistratio Title 22 madates the CHC must have a goverig body, kow as a board of directors. As the full legal goverig body, the board has full resposibility for cliic operatios ad compliace with regulatios. Such duties, as set by HRSA, iclude holdig mothly meetigs, approval of the health ceter s grat applicatio ad budget, selectio of services to be provided ad the health ceter s hours of operatios, ad establishmet of geeral policies for the health ceter. 2 The voluteer board, which should be at least ie members but o more tha 25, is composed both professioals ad patiets. A key stipulatio to make sure the CHC is meetig the eeds of the patiets it serves is the requiremet that more tha 50 percet of the board must be patiets who actually utilize the services provided by the CHC. 2 Board members customarily have differet professios by day; they ca be attoreys, farm workers, stay-at-home parets, or commuity leaders all of whom share a commitmet to leadig a ot-for-profit orgaizatio. They should be selected for their expertise i commuity affairs, local govermet, fiace ad bakig, legal affairs, trade uios, ad other commercial ad idustrial cocers, or social service agecies withi the commuity. 2 I order to oversee the day-to-day operatios of a CHC, Title 22 ad HRSA holds the board to be resposible for hirig a admiistrator or executive director, ED. 2,14 The ED maages the daily fuctios of the cliic, or cliics if there are multiple sites, ad oversees the performace of health care give to the patiets with medical ad detal directors. The ED ad is resposible to lead the CHC ad work with the board. The board sets the qualificatios eeded for the job, sets the parameters, ad moitors the may

6 health ceters cda joural, vol 37, º 5 table 5 Califoria Health Ceter Staffig ad Utilizatio State Summary for Califoria, 2007, From a Total of 110 Gratees PERSONNEL BY MAJOR SERVICE CATEGORY Total physicias (all categories) Nurse practitioers Physicia assistats Certified urse midwives Total midlevel practitioers Full-Time Employees (a) Ecouters (b) Patiets (c) FTEs as Percet of Group FTEs as Percet of Total Ecouters as Percet of Group Ecouters as Percet of Total Ecouters per FTE 1, ,377, % 6.7% 63.6% 45.1% 4, ,116, % 2.1% 16.2% 11.5% 3, ,014, % 1.7% 14.7% 10.5% 3, , % 0.3% 1.9% 1.3% 2, ,259, % 4.1% 32.8% 23.3% 3,426 Nurses , % 3.8% 3.6% 2.6% Total 5, ,885,384 2,023, % 32.3% 100.0% 70.9% 2,930 medical care services (ot icludig physicias) Detists , % 1.9% 96.5% 10.2% 3,191 Detal , % 0.2% 3.5% 0.4% 1,234 hygieists Detal % 4.1% assistats, aides, ad techicias Total detal services (lies 16-18) ,024, , % 6.2% 100.0% 10.6% 3,022 Source: HRSA Uiform Data System for Califoria, performace of the ED. A ED ca have a college degree or postgraduate degree, but a medical degree is ot required. Detal Director If detal services are provided, the CHC appoits a licesed detist as the detal director to oversee the detal program uder the leadership of the medical director. 14 The typical detal director/detist performs detal care for the patiets i additio to admiistrative work. I fact, a sigificat portio of the detal director s time is allocated to provide direct patiet care, ofte 90 percet or more, leavig the remaider of the usual 40-hour workweek devoted to admiistratio duties. The detal director must be efficiet i balacig duties. The detal director ca ofte be foud i the middle of performig detal services whe asked to address a immediate cocer of the detal cliic because admiistratio of the cliic must occur every hour the cliic is ope, whether it is durig admiistrative time or ot. Typically, the detal director performs all detal scopes of services provided at the cliic. The detal director supervises the staff detists workig at the cliic ad esures all follow policies ad regulatios for the cliic. Just as with the medical director, the detal director is resposible to maitaiig quality of care provided at the CHC. The detal director s admiistrative duties are umerous. The resposibilities iclude overseeig the day-to-day operatios of the cliic, moitorig 324 may 2009

7 cda joural, vol 37, º 5 daily patiet flow, reviewig ad makig budgetary decisios, maitaiig cliic compliace with regulatios, writig ad reviewig office policy mauals, overseeig patiet care quality, ad maagemet of staff. 12 The detal director ca be part of the executive maagemet team resposible for workig with the ED for the overall performace ad success of the cliic, which requires attedace at various meetigs. Staff Detist CHCs typically recruit detists who are iterested i workig at the commuity level with a strog commitmet to public service. 12 It is difficult to recruit for CHC detists i Califoria. 4,12 The No. 1 factor for a detist to stay employed with a CHC is the desire to take care of the uderserved commuity or a altruistic motivatio. 16 There are full-time equivalet detists workig at the 110 Sectio 330 gratee HCs i Califoria 9 (table 5). The average salary of a detal director is $133,000; the average salary of a staff detist is $107,000, accordig to a idepedet salary survey coducted o 75 primary care detists i Alaska, Arizoa, Califoria, Nevada, ad/or the Pacific Territories of the Uited States i Aother smaller survey i 2008 reported the average staff detist is paid $52 to $62 per hour, or a full-time average of $118,560 per year. 12 As a frame of referece, the America Detal Associatio reports the average earigs for a geeral detist who owed his/her office is more tha $198,000, as of The CHCs commoly give sigificat beefits to full-time employees, such as vacatio leave, sick leave, multiple paid holidays, cotiuig educatio allowace, professioal liability coverage, disability ad life isurace, matchig beefits to a 403(b) self-fuded retiremet pla, ad full medical, detal, ad visio isurace. Oe source for fidig detists is by offerig the Natioal Health Service Corps, NHSC, loa repaymet program. By usig Health Professios Shortage Area (HPSA) scores, areas of greater eed or uderrepresetatio ca offer medical or detal school loa repaymet up to $50,000 based o a miimum two-year employmet commitmet at the CHC. 18 The loa repaymet is above ad beyod the staff detist s salary. More tha 78 percet of NHSC cliicias cotiue to work i uderserved commuities after their commitmet eds. 18 the o. 1 factor for a detist to stay employed with a CHC is the desire to take care of the uderserved commuity or a altruistic motivatio. 16 Other persoel at the CHC detal cliic iclude a cliic or office maager, detal hygieists, registered or uregistered detal assistats, frot desk persoel, ad other admiistrative employees related to processig or billig for services who ofte oversee billig for both detal ad medical services. Few detal hygieists are employed at Califoria s 110 FQHCs, oly 29.2 full-time equivalet detal hygieists, compared to full-time equivalet detists. Assistat persoel total full-time equivalet employees, or slightly more tha two per each full-time detist 9 (table 5). Patiet Care: Possible Types of Coverage CHC detal cliics provide care to patiets who have more complex detal eeds, poor compliace, ad more medically compromisig coditios tha those see at the private practice. 12 The patiet populatio at commuity cliics sometimes dictate the scope of services provided. 11 Some cliics have a high percetage of Medicaid (Medi-Cal) ad some have more patiets o a slidig fee scale. Some do ot participate i ay commercial private isurace plas ad there are those who sig up with several. There are three major types of reimbursemet at the detal CHC site: 1. Medi-Cal Detal Program. The Califoria Medi-Cal Detal program is differet tha the Deti-Cal program i private practices. Private practices are required to sed treatmet authorizatio requests or preauthorizatios to Deti-Cal whereas the HCs are ot. The Medi-Cal Detal program for HC detal cliics is admiistered through Medi-Cal ad reimbursemet is based o ecouters or direct patiet visits istead of by procedure. However, HCs must follow the same Deti-Cal treatmet guidelies as the private practices ad documet such ratioale for treatmet i the patiet record, which is audited. It is the resposibility of the detal director to make sure the guidelies are clearly uderstood ad followed by the HC staff. Each state idividually determies the scope of Medicaid detal services for adults sice it is a beefit that is ot required by the federal govermet. 19 This is oe of the reasos why the adult Medi- Cal detal coverage i Califoria has ofte bee at risk of beig elimiated durig state budget egotiatios i Sacrameto. 2. Couty Medical Services Program. The commuity cliic s relatioship may

8 health ceters cda joural, vol 37, º 5 table 6 Califoria Health Ceter Data Patiet Care: Scope of Service The Bureau of Primary Health Care that directly oversees FQHCs uder HRSA madates that prevetive ad emergecy detal care ad detal screeig for all childre are to be made available to all patiets if the ceter has a detal cliic. If the ceter does ot have a detal program o site, the ceter is required to make arragemets for referrals to a private practice or other cliics through a cotractual agreemet. 3 No two CHC detal cliics are alike. Some cliics are so iudated with patiets ad ca oly provide emergecy care ad possibly prevetio. Others, with differet ifrastructure or populatios, ca provide a wider scope of detal care ragig from prevetio, comprehesive services from amalgams, composites, root caal therapy ad periodotal procedures to recostructive services such as crow ad bridge, ad eve implat services ad cosmetics. That is why those who have worked i a commuity cliic say, If you ve see ONE commuity health ceter, you ve see ONE commuity health ceter. The type of treatmet ad scope of service provided for patiets at a commuity health ceter detal cliic should ot be ay differet from that of the private sector. CHC patiets are ecouraged to become regular patiets with comprewith the couty public health departmet ca also have a impact o its capacity. Some Califoria couty health departmets offer detal services, however, most do t. The couties ca refer their eligible patiets to the CHCs to receive care through couty medical services program, CMSP, a special program for a couty s ow idiget residets. This program was started i 1983 whe the State of Califoria trasferred the resposibility of takig care of this group of patiets to the couties. CMSP is ot a Deti- Cal program but the services provided are ofte similar, although they ca differ per couty. The scope of services of CMSP program is decided by a goverig board istead of the state s Departmet of Health Care Services Slidig Fee. HCs are a great opportuity to provide detal care to the lower socioecoomic populatio because HRSA requires care to be provided regardless of the patiet s ability to pay. CHCs offer a slidig discout based o family size ad icome. This sigificat discout of UCR fees is give to idividuals ad families with aual icome is at or below the federal poverty guidelies ad for those with icomes betwee 100 percet ad 200 percet of poverty. 2 It should be emphasized that patiets do ot subjectively tell the HCs their ability to pay, but their documeted icome level (copies of tax returs) ad family size set by stadard HC policies will objectively dictate their ability to pay. Patiets who seek emergecy services ad treatmet to relieve pai are ot tured away if they caot pay. HCs also provide services at direct fee-for-service. Private isurace plas make up a small part of the patiet populatio at the CHC. Number of HC cliic sites Number of FQHC sites Number of FQHC look-alike sites Source: Califoria Office of Statewide Health Plaig ad Developmet, compiled by Califoria Primary Care Associatio data 2005 data % icrease % % % Total patiets 2,200,156 3,645, % Total ecouters 6,869,492 11,286, % hesive exams ad follow-up treatmet. The cocept of havig a detal/medical home is the goal of all commuity cliics. CHC detal cliics provide detal care to all ages. Childre uder the age of 5 are ecouraged ad welcome, ad ofte childre as youg as 1 year old are see with importat aticipatory guidace. The traiig ad the mix of providers at the ceters also dictate the types of care provided. Most CHC detal cliics employ geeral detists, who, i order to successfully take care of the patiets eeds, must have much experiece i providig extractios ad root caals. 12 There are a few who are able to recruit specialists to joi their staff. These ceters, of course, will be able to provide more specialty services to their patiets. The 2000 Geeral Surgeo s Report clearly illustrated the very grim picture of oral health status of the low socioecoomic patiet populatio, which is the core group of patiets that commuity cliics serve. 21 It comes as o surprise to ay that the eeds of the commuity ofte exceed the capacity of the health ceter. 12 It is ot ucommo to see that a ew cliic reaches its capacity shortly after it opes. A log wait for a appoitmet, three moths or loger, is ot uusual. The familiar sayig for those who have worked at CHCs for a log time is that for every ew expasio, the cliic 326 may 2009

9 cda joural, vol 37, º 5 table 7 Former Presidet George W. Bush s First Health Ceter Iitiative, Improvemet i Califoria Califoria s uderserved beefited from former Presidet George W. Bush s 2002 multiyear iitiative for the Federal Cosolidated Health Ceters Program uder Sectio 330. For the first five years of the Program i Califoria: 79 ew health ceter sites have bee established. 49 health ceters have substatially expaded their capacity to serve more patiets. Seve health ceters have expaded ad improved their metal health ad substace abuse programs. 23 health ceters have expaded ad improved their detal programs. Source 4 : Califoria Primary Care Associatio. Quality Assurace Regardless of whether the detal services are provided o site or off site, CHCs are required to have a quality assurace program that follows extesive federal requiremets o cliical care stadards as a way to moitor the quality of care provided to their patiets. 6 Quality assurace starts out at the time of hirig. Providers must go through itesive backgroud ad referece checks. This is a very importat aspect for CHCs because of the deemig process for Federal Tort Claims Act, FTCA, credetialig, which provides the professioal liability for the providers. Most CHCs also purusually outgrows the ew site eve before it moves i. Califoria s HCs cotiue to grow i umbers of sites, patiets see, ad umber of patiet visits (table 6). As some cliic patiets may be receivig detal care for the first time i their lives, patiet educatio o prevetio is a importat aspect of the commuity cliic operatio. The staff of a CHC is traied o providig oral hygiee istructio as well as the etiology of the periodotal disease, its treatmet ad prevetio. As with patiets i the private sector, oral disease prevetio is ofte a difficult cocept for CHC patiets. Due to fiacial reasos, may may opt for o treatmet, a commo reality that sometimes frustrates may cliic providers. Every treatmet has to be explaied to patiets very clearly to esure the patiets are makig the right, well-iformed decisios. Sice most detal cliics are colocated with a medical compoet, there is usually some itegratio betwee detal ad medical care of the patiets. For example, if a medical compoet is participatig i a health disparities collaborative to improve the health of vulerable populatios, the detal cliic will also participate i the atioal collaborative ad track iformatio o a selected oral health measure. 5 Oe example is i the diabetes health disparity collaborative. The HC health care pla or strategic pla usually reflects the aspect of itegratio of medical ad detal care. 19 Pediatric referrals are a example. If it is oe of the objectives of the health care pla to refer pediatric patiets to the detist for a examiatio by age 1, the patiets will be more tha likely to be see i detal at a earlier age tha if the health care pla does ot address oral health care. A additioal itegratio example of the health care pla is a preatal program. CHC patiets who are pregat are routiely referred to detal for a periodotal check up ad treatmet whe the staff uderstads the relatioship betwee periodotal disease ad preterm, low birthweight. chase additioal wraparoud malpractice isurace for its detists, physicias, ad other cliical providers. The providers ad cliical staffs have to be privileged ad credetialed aually to cotiue practicig at the ceters. This process icludes, but is ot limited to, reviewig detal liceses, DEA licesig, ad CPR reewals. Quality assurace also miimally icludes a periodic chart audit system ad peer-review process to review the appropriateess of services as well as quality. 2 The audit ad peer review as well as the frequecy are set by the detal director or the quality assurace/compliace officer of the health ceter. The audit ca also be doe by all providers workig at the cliics. Some cliics choose to hire a outside cosultat, usually someoe who is familiar with commuity health ceter settig or a local detist of a detal society who is familiar with the peer-review process. Either way, it is to be a regular part of the cliic operatios ad a requiremet for federal grat applicatio. I the quality assurace protocol, a improvemet or correctio pla has to be icluded, should a deficiecy be discovered. A patiet satisfactio survey is aother tool the cliics use to gauge their progress ad performace. All the quality assurace activities ad fidigs are reported to the executive maagemet/ leadership team ad board of directors. Fially, all of the health ceters are required to go through HRSA performace reviews, doe by the Office of Performace Review, OPR. Durig a performace review, the CHCs have to select a outcome measure that it wats to moitor ad report periodically to the OPR. 22 For example, commo measures selected for reviews iclude treatmet completio rate or caries rates amog pediatric patiets. Data collectio is a ecessary part of the life of a health ceter to evaluate results i providig care to the uderserved. may

10 health ceters cda joural, vol 37, º 5 Coclusio Health ceter detal cliics udeiably improve access to care by providig services to patiets who do ot ormally seek detal care i the private sector. The Office of the Surgeo Geeral i 2003 reported, No oe should suffer from oral diseases or coditios that ca be effectively preveted ad treated. No schoolchild should suffer the stigma of craiofacial birth defects or be foud uable to cocetrate because of the pai of utreated oral ifectios. No rural ihabitat, o homeboud adult, o ier city dweller should experiece poor oral health because of barriers to access to care ad shortages of resources ad persoel, accordig to the Natioal Call to Actio to Promote Oral Health. 23 Yet, eve with a icrease i access available to Califorias i eed, a commo problem expressed by a recet survey of stated that CHCs still believe they do ot have the capacity to meet all the detal eeds of this uderserved populatio. 12 There is good ews. Former Presidet George W. Bush made CHCs the ceterpiece for his health care pla. 8 Uder Bush, with bipartisa support from the Cogress, federal fudig for CHCs doubled ad 1,297 health ceter cliic sites have bee created or expaded over the past eight years i the Uited States. 24 Califoria greatly beefited from the Bush s Health Ceter Iitiative (table 7). HCs ad their support orgaizatios hope this expasio of health ceters ad detal cliics will cotiue uder Presidet Barack Obama as he ad the Cogress shape a uiversal health care proposal. More oral health access expasio grats from HRSA are ecessary to cotiue to provide health ceters with fudig to improve access to care. Fially, a board member of the Natioal Network for Oral Health Access, a member- ship orgaizatio of commuity health ceter providers, staff ad advocates, oce said, We ca t afford ot to do it right (create a CHC) the first time sice we do t have a secod chace to do it over because the waitig list is too log ad we ca t accommodate the eeds. refereces 1. HRSA, bphc.hrsa.gov/about/legislatio/sectio330.htm. Accessed March 3, HRSA, bphc.hrsa.gov/about/. Accessed March 3, HRSA. The health ceter program: policy iformatio otice 98-23: health ceter program expectatios. bphc.hrsa.gov/ policy/pi9823/default.htm. Accessed March 3, Schacht J, The future of commuity cliics ad health ceters i Califoria s safety et: A blueprit for actio, 2007 Update, Califoria Primary Care Associatio, pages 1-55, April 13, cpca.org/resources/research/documets/2007_cpca_blue- PRINT_UPDATE_FINAL pdf. Accessed March 3, Proser M, Special topics issue brief No. 2: The role of health ceters i reducig health disparities. Natioal Associatio of Commuity Health Ceters, pages. 1-16, July achc.org/ cliet/documets/publicatios-resources/2.pdf. Accessed April 21, Shi P, Joes K, et al, Reducig racial ad ethic health disparities: Estimatig the impact of high health ceter peetratio i low-icome commuities. CPCA, September cpca.org/resources/research/pdf/gwu_disparities_report. pdf. Accessed March 3, Commuity cliics iitiative. Abstract: Assessig the capacity of Califoria s commuity cliics. CCI Report to the Field, pages 1-5, July cpca.org/resources/research/pdf/capacityofcacommuitycliics.pdf. Accessed March 3, Schacht ad Associates, The vital role of commuity cliics ad health ceters: Assurig access for all Califorias. CPCA, pages 1-10, March UDS, Califoria data, bphc.hrsa.gov/uds/2007data/ califoria/table5.htm. Accessed March 3, Byck GR, Cooksey JA, Hollis R, Safety-et detal cliics: A viable model for access to detal care. J Am Det Assoc 136: , Scott M, Bigham D, Doherty M, The good practice: Treatig uderserved detal patiets while stayig afloat. Califoria HealthCare Foudatio, pages 1-40, August chcf.org/ topics/view.cfm?itemid= Accessed March 3, Diriger ad Associates, Expadig access to detal care through Califoria s commuity health ceters. Califoria HealthCare Foudatio, August chcf.org/topics/medical/idex.cfm?itemid= Accessed March 3, Califoria Departmet of Health Care Services, cdph. ca.gov/pubsforms/forms/documets/cliicfacilityapprequestltrchecklist.pdf. Accessed March 3, Califoria, Barclays Califoria Code of Regulatios. Title 22, chapter 7, Primary care cliics, pages , April Califoria Departmet of Health Care Services. cdph. ca.gov/pubsforms/forms/pages/healthfacilities.aspx. Accessed March 3, Boli KA, Shulma JD, Natiowide survey of work eviromet perceptios ad detists salaries i commuity health ceters. J Am Det Assoc 136:214-20, Saker P, Regio IX salaries results. Ho`ola Lahui Hawaii Kaua`i commuity health ceters, persoal correspodece, March HRSA, Natioal health service corps fact sheet. ftp.hrsa. gov/factsheets/bcrs.pdf. Accessed March 3, HRSA. hrsa.gov/medicaidprimer/oral_part3oly.htm. Accessed March 3, CMSP. Accessed March 3, U.S. Surgeo Geeral, Oral Health i America: www2.idcr. ih.gov/sgr/sgrohweb/welcome.htm. Accessed March 3, HRSA. hrsa.gov/performacereview/tutorial/text/s1_p01. htm. Accessed March 3, U.S. Departmet of Health ad Huma Services. Natioal call to actio to promote oral health. Rockville, Md., U.S. Departmet of Health ad Huma Services, Public Health Service, Ceters for Disease Cotrol ad Prevetio, Natioal Istitutes of Health, Natioal Istitute of Detal ad Craiofacial Research, NIH publicatio Sack K, Bush has built foudatio for improved health care: Expasio of cliics shapes Bush legacy. New York Times, Dec. 25, to request a prited copy of this article, please cotact Bria K. Shue, DDS, Cliicas de Salud del Pueblo Ic., 166 K St., Brawley, Calif., may 2009