A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net Dental Clinics

Transcription

1 A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net Dental Clinics Findings from an Evaluation of the Strengthening Community Dental Practices Demonstration Project January 2011 Prepared by Clare Nolan Fontane Lo Katherine Lee

2 table of contents Executive Summary i 1. Introduction 1 The Strengthening Community Dental Practices Demonstration Project 2 Evaluating the Success of SCDP 3 2. Participating Clinics 7 3. Implementation and Results 8 Overall Success of Practice Management Consulting 8 Satisfaction with Consulting 10 Strategies for Clinic Impact Consulting Model 18 Strengths and Weaknesses of the Consulting Model 18 Factors that Influenced Success 20 Improving the Design of Consulting Model Considerations for Future Work Discussion and Recommendations 27 Consultant Characteristics 27 Appendix A: Clinic Case Studies 30 Clinicas de Salud del Pueblo 31 Community Oral Health Services 34 County of Marin Dental Services 37 Del Norte Clinics 40 Inland Behavioral and Health Services 43 La Clínica de la Raza 46 Mission Community Hospital Dental Clinic 49 Native American Health Center 52 Vista Community Clinic 55 Appendix B: Clinic Attributes and Data 58 Appendix C: Clinic Goals and Outcomes 60 Appendix D: Clinic Communities 62 Appendix E: Interview Participants 63

3 Executive Summary Strengthening Community Dental Practices The primary mission of community dental practices is to serve to low-income, underserved populations who could not otherwise afford care. However, the recent economic downturn and fiscal crisis have made it increasingly difficult for community dental practices to both uphold this mission and keep their doors open. California s fiscal crisis has led to significant cuts to public dental benefits for adults, and has reduced local and private funding factors which have only exacerbated these difficulties. Strengthening Community Dental Practices (SCDP) was a joint project by the California HealthCare Foundation (CHCF) and the California Pipeline Program. The purpose of this pilot project was to ascertain the effectiveness of practice management consulting, an intensive year-long engagement of individualized assistance aimed at improving the long-term sustainability of safety net dental clinics. Harder+Company Community Research ( a California-based consulting firm specializing in research and planning for the health and social service sectors, was commissioned to independently evaluate the potential of practice management consulting to strengthen community dental practices. Participating Clinics Nine pilot clinics were selected for participation, broadly representing the diversity of safety net dental clinics in California. Clinics varied by type (federally qualified health centers, public health clinics, nonprofit clinics), size and structure (mobile, single-site, multi-site), setting (urban and rural), tenure (start-up and more established practices), and patient mix (serving primarily adults or primarily children). Management Consulting Providers Safety Net Solutions (SNS) and Pride Institute were contracted to provide practice management consulting services. SNS is a program of Dentaquest Institute, a Massachusetts-based oral health organization that specializes in consulting services for safety net dental clinics. SNS s model is rooted in their consultants deep experience in community dental practice, and they work with clinics to implement specific operational improvements. Pride Institute is a California-based consulting firm that provides consultation primarily to private dental practices. Pride Institute s model is rooted in clinic education, organizational development, and an internal culture of change. Pride Institute consultants worked with clinics to develop a vision, and they rely on the self-direction of clinic leadership to implement changes. Summary of Findings Each clinic faced unique challenges and limitations in their daily operations, and therefore experienced varying levels of success from the consulting engagement. This section discusses the overall success of practice management consulting, identifies strategies that the participating clinics found most helpful, and outlines considerations for future work. Prepared by Harder+Company for the California HealthCare Foundation January 2011 i

4 Overall Success of Practice Management Consulting In this evaluation, success is defined as the added value of consulting services to clinic management and operations. In other words, this evaluation does not aim to assess the clinic, but the effectivenessness of practice management consulting on clinic operations. While the data available does not permit a rigorous comparison across clinics, * Exhibit ES1 provides a framework with rankings of relative success based on a review of clinic staff interviews and self-reported financial and operational measures. Three of the clinics realized a high degree of success, three experienced moderate success, and three experienced low success with practice management consulting. Clinic success is ranked along four dimensions: (1) breadth of implementation, or the degree to which clinics implemented the consultant s recommendations, (2) financial improvement (e.g., changes in revenue, patient load, or patient mix), (3) operational improvement as indicated by no-show rates, wait time for appointments, and clinic staff reports, and (4) anticipated longevity of improvements over time. With regard to the last dimension, improvements were judged as long-lasting if clinic staff buy-in was high and improvements aligned with clinic mission and values. Exhibit ES1: Assessment of Consulting Success Clinic Overall Success Breadth of Implementation Improved Finances* Changes to Operations Longevity of Improvements Vista Community Clinic High High High High High Community Oral Health High High High High Moderate Services Inland Behavioral & Health High High Moderate High High Services County of Marin Dental Moderate Moderate High Moderate Moderate Services Mission Community Hospital Moderate Moderate Moderate Moderate Moderate Native American Health Moderate High Low Moderate High Center Clinicas de Salud del Pueblo Low Moderate Low Moderate Low Del Norte Clinics Low Low Low Moderate Low La Clínica de la Raza Low Low Low Moderate Low * All financial calculations exclude grant funding. Despite varying degrees of success, all nine clinics reported satisfaction with the consulting services they received through SCDP. The clinic expressing the least satisfaction ( somewhat satisfied ) discontinued their involvement with SCDP half-way through the project year due to changes in dental clinic leadership. Clinics reporting lower levels of satisfaction tended to have no internal champion for the project and minimal buy-in from clinic staff and management. Strategies for Clinic Improvement Of the strategies recommended by the consultants, four areas seemed to help clinics make the greatest strides toward sustainability. However, findings also suggest that there is no one-size-fits-all recipe, * Available data includes interviews with key informants at two points in time and quarterly practice-related measures. While consistent with standard practices in evaluation, the available data only captures snapshots in time with select informants. Prepared by Harder+Company for the California HealthCare Foundation January 2011 ii

5 and what worked well for some clinics did not work well for others. The unique qualities and characteristics of each clinic therefore necessitate a tailored approach. Adjusting fee schedules. Given their mission to serve low-income and uninsured patients, many clinics charged fees well below the usual rates for the area. Consultants suggested fee increases coupled with a steeper sliding scale such that patients at the highest tier would pay more while relieving the financial burden for patients at the lowest tier. As a result, clinics would collect higher fees from those who could afford it while providing larger subsidies for those at the lowest income levels. Some clinics saw significant increases in revenue (such as Vista Community Clinic). Other clinics (such as Mission Community Hospital), however, felt the fee increases conflicted with their mission and purpose. Modifying patient mix. Due to significant cuts to adult public dental benefits, consultants advised clinics to focus their efforts on pediatric patients. Patient mix modification is a strategy that enables struggling clinics to maintain financial solvency while meeting their goal of serving uninsured adults. While uninsured adult patients would not be turned away, they may have to wait longer for non-emergent care (up to 30 days at most clinics). Many clinics took this strategy to heart and successfully recruited pediatric patients into their practices through active outreach (such as those instituted by Inland Behavioral and Health Services) and portable clinics at schools (such as Native American Health Center). However, clinic data reveal that modifying patient mix may not guarantee more patients with dental insurance. Altering scheduling practices. Though sometimes seen as a peripheral function in clinics, scheduling practices are a cornerstone of clinic efficiency and financial viability. A clinic s schedule sets the pace and flow for clinic staff and determines which patients will have access to services. Scheduling practices have considerable potential to reduce the sense of chaos in daily operations while maximizing the use of each dentist s time, not only with regard to the number of patients served but also to the quality of care provided. While altering scheduling practices helped reduce stress levels at some clinics (such as County of Marin Dental Services), it also created greater stress and anxiety at others (such as Clinicas de Salud del Pueblo). Establishing policies and procedures. Policies and procedures help standardize and bring greater transparency to how staff members respond to patients in daily interactions. While policies and procedures entail a broad range of strategies, this section focuses on the most noteworthy: no-show policy, triage process, proof of income, follow-up on account receivables, and clarification of internal policies. Many clinics reported success in reducing no-show rates, reducing clinic stress levels, and improving their ability to collect payments from patients. One clinic (La Clínica de la Raza) focused on building a stronger foundation for change by clarifying staff responsibilities, billing policies, and management practices. Clinics appreciated that consultants were able to identify what they needed and then bring in policies and procedures that clinics could tailor to their needs. In each of these strategy areas, it is important to recognize that some people benefit from changes, and others do not. When clinics increase fees, some patients must pay more for services. When clinics elect to enforce a no-show policy, some patients may have to wait longer for care. These are the tradeoffs with which clinics struggle in order to keep their doors open and maintain services for underserved populations. Prepared by Harder+Company for the California HealthCare Foundation January 2011 iii

6 Consulting Model Practice management consulting is a relatively new model for strengthening the financial viability of safety net dental practices. SCDP has shown that the results of practice management consulting may vary across clinics, as shown in Exhibit ES1. The experiences of the nine clinics point to several factors that create an environment for success. By understanding these factors and addressing them prior to the engagement, clinics may experience greater and more predictable success with practice management consulting. Successful clinics reported that the consultants brought deep knowledge as practicing community dentists, and understood the legal mandates and strict reimbursement guidelines under which safety net clinics operate. Furthermore, clinics appreciated consultants who approached them as collaborative partners rather than simply telling them what to do. As one staff member relayed, They worked with us to develop recommendations and strategies. They didn t tell us what to do. It was a collaborative effort and they spoke with authority, knowledge, and experience. From the experiences of the nine pilot clinics, six factors arose as key elements of success: Buy-in from executive leadership and clinic staff. Buy-in, defined as a strong sense of ownership in the work and a drive to advocate for change, is critical for establishing openness to change and strengthening follow-through in the implementation phase. In particular, it is important to determine whether the executive leadership is fully committed to the project and will provide the leadership, resources, and support necessary for successful implementation. Project champions. Strong project leaders have a vital role in gaining buy-in at all levels and helps clinic staff to maintain focus on the task at hand. It is important that project champions exist at both the executive and clinic levels. At the executive level, the project champion should be able to effectively communicate progress and obtain resources. At the clinic level, the project champion should have a deep understanding of day-to-day clinic operations, and should be wellpositioned to communicate clinic concerns upward to the executive leadership. A culture that supports change. Cultural norms at the executive and clinic levels can either support or inhibit change. It is important to determine whether it is safe and encouraged to speak up, and whether the organization s culture nurtures, rather than stifles, change and innovative thinking. Clear and compelling project goals. Clear goals help staff at all levels understand why changes are necessary and maintain focus on the work. With the hectic schedules and high stress levels typical of safety net clinics, clear goals ensure more follow-through in the implementation phase. Availability of resources for consulting work. A successful consulting engagement not only requires the dedication and commitment of clinic staff, but also concrete resources in terms of release time for staff members to do the work, data capacity to diagnose and monitor clinic needs, and adequate technological resources to support change. Consultation customized to address clinic needs. New clinics and established clinics face different barriers and concerns in the consulting process. New clinics seek an infusion of knowledge and expertise, and often have a high level of buy-in and commitment at the start. On Prepared by Harder+Company for the California HealthCare Foundation January 2011 iv

7 the other hand, established clinics often need someone to help push them beyond old habits and adopt best practices. Exhibit ES2 offers a potential typology for considering clinic needs and the possible implications for the consulting approach. Exhibit ES2: A Potential Typology of Clinic Needs Clinic attributes High Stress High Resistance Positioned for Change Chaotic and stressful clinic operations. Limited staff time and data capacity to participate. Champion sees need for change but faces resistance. Needs third party to help prioritize resources. Well-positioned for change, but needs tools and/or buyin to move forward. Consulting approach Coach. Clinic has minimal culture of change. Help managers see why operations are stressful so they recognize need for change. Facilitator. Clinic is ready to expand culture of change. Extend buy-in to clinic staff and executive leadership to enable implementation. Catalyst. Clinic already has culture of change. Help identify final pieces required to put ideas into action. Case examples Del Norte Clinics, La Clínica de la Raza Clinicas de Salud, Native American Health Center Vista Community Clinics, Inland Behavioral & Health Services Lessons and Considerations for Future Work Interviews with oral health care stakeholders and potential partners reveal that there is a clear need for practice management consulting among safety net dental clinics. Interview participants expressed that many clinics are too overwhelmed to think about practice management, and they typically lack the financial resources to pay for this type of assistance on their own. A number of clinics outside of this study expressed that they could definitely benefit from practice management consulting. However, this demonstration reveals that successful implementation requires key elements such as buy-in at the executive and clinic levels, project champions within the clinic and in the administration, a culture that supports change, clear and compelling project goals, and the availability of resources for the consulting work. Some clinics may require support in addressing these requisite elements in order to support an effective change process. In considering future work, oral health care stakeholders and potential partners agree that it would be important to capture the long-term impact of practice management consulting. Areas of impact should include not only financial viability, but also quality of care and prevention in the long term. Recommendations Findings from the evaluation thus far suggest that, while practice management consulting is not a cure-all, it shows great promise for helping clinics achieve a productive balance between their public health missions and fiscal solvency. Case studies of the nine pilot clinics revealed several key elements that create an environment for success. Clinics were more likely to experience success if a number of key elements were in place prior to the engagement: executive and clinic-level support for the work, strong project leadership, a culture that supports change, compelling project goals, and the availability of resources for the consulting work. By helping clinics to address these factors prior to the consulting engagement, practice management consulting projects will be more well-positioned for success and for maximizing social impact. Prepared by Harder+Company for the California HealthCare Foundation January 2011 v

8 Successful clinics were more likely to describe their consultant as having two key characteristics: significant credibility as practicing community dentists and a collaborative approach in which clinics were viewed as partners in change. Credibility and a collaborative approach made clinic staff more receptive to suggestions and more open to change. For some clinics, there may be alternative modes of assistance that more directly address their needs. For example, public policy may be a better tool for addressing the scarcity of public funding for adult dental services, and leadership training may be a better tool to help executive level leadership and clinic managers develop the foundational skills needed in order to push for greater change in the future. Overall, clinics expressed a high level of satisfaction with the consulting model. However, findings also point to potential refinements to the model. Some clinics felt overwhelmed by the long list of recommendations, and suggested that the work could be divided into modules so that they could focus on one operational area at a time. Furthermore, increasing hands-on assistance from consultants during implementation and with facilitating buy-in may lead to greater follow-through of the recommended improvements. Conclusion Safety net dental clinics strive to maintain a fine balance between upholding their mission and maintaining financial viability. Serving those most in need regardless of ability to pay while also collecting enough revenue to keep clinic doors open can be quite a challenge. It is especially difficult to achieve this balance during a time of declining resources, high unemployment, and growing patient need. The nine demonstration clinics illustrate some of the difficult decisions and uncomfortable tradeoffs that safety net clinics must make. Findings from the evaluation suggest that practice management consulting, while not a cure-all, shows promise for helping clinics achieve a productive balance between their public health missions and fiscal solvency. Prepared by Harder+Company for the California HealthCare Foundation January 2011 vi

9 1. Introduction California s community dental practices work hard to achieve a productive balance between meeting their public health missions and maintaining financial viability. 1 However, a statewide fiscal crisis compounded by the recent economic downturn has created unprecedented challenges for community dental practices across the state. These trends threaten the sustainability of safety net dental clinics and may ultimately reduce access to care for many low-income and uninsured Californians: The California Legislature eliminated most Medi-Cal dental benefits for adults effective July This public program had been the primary payer source for most safety net dental clinics in California and was a vital source of coverage for more than three million Californians. 3 As resources are waning, the demand for safety net services is rising. California s high unemployment rate (12.4 percent as of December 2010) speaks to the rising uninsured population. Many dental practices are faced with declines in funding from private foundations and local agencies. Without these funds, clinics are less able to subsidize care for the uninsured. Even as challenges mount, there are still opportunities for growth through the Patient Protection and Affordable Care Act of 2010 (PPACA) and the American Recovery and Reinvestment Act of 2009 (ARRA). The implications of PPACA remain uncertain. Safety net clinics have the potential to either thrive or become marginalized by the new reforms. Still, PPACA presents an opportunity for clinics to strengthen their services, networks, and infrastructure provided they can contain costs. 4 ARRA allotted $1.5 billion of infrastructure improvement funding and $500 million of operations funding for federally qualified health care centers nationwide. 5 ARRA s implications for community clinics include: Many health centers are moving toward electronic record systems, which have the potential to greatly improve the operational efficiency of safety net dental clinics. Federally qualified health care centers have additional funding at their disposal, some of which could be directed toward improving efficiency and quality of safety net dental services. 1 For further context regarding challenges faced by safety net clinics, please refer to: California HealthCare Foundation. California s Safety Net Clinics: A Primer, 2009; California HealthCare Foundation. The Good Practice: Treating Underserved Dental Patients While Staying Afloat, The cuts did not affect federally-required adult dental services (primarily emergency services), pregnancy-related services, and dental services for persons living in nursing facilities were not cut. 3 Oral Health Access Council, California Primary Care Association, and the Dental Health Foundation. Eliminating Medi-Cal Adult Dental: Costs and Consequences, Katz, Mitchell H. Future of the Safety Net Under Health Reform. JAMA. 2010; 304(6): National Association of Community Health Centers. The American Recovery and Reinvestment Act of 2009: Frequently Asked Questions, Prepared by Harder+Company for the California HealthCare Foundation January

10 The Strengthening Community Dental Practices Demonstration Project The Strengthening Community Dental Practices (SCDP) demonstration is a joint project between the California HealthCare Foundation (CHCF) and the California Pipeline Program. 6 While the goals of each entity are unique, both have an interest in the management and sustainability of safety net clinics. SCDP is a pilot project to ascertain the effectiveness of practice management consulting, an intensive year-long engagement of individualized assistance aimed at improving the long-term sustainability of safety net dental clinics. The goals of CHCF s Innovations for the Underserved program are to promote lower-cost models of care, improve access to care for under-served populations, increase patient enrollment and retention in public health care programs, and improve operational efficiency of the safety net. California Pipeline Program partners with community clinics to provide training for dental students. The program aims to help dental students build greater competency in serving diverse populations while also providing needed services in community clinics and encouraging more students from low-income and under-represented communities to join the dental profession. CHCF and the California Pipeline Program saw a synergistic partnership clinics need dentists who are committed to community dentistry, and operationally strong clinics provide better learning opportunities for dental students. Clinic selection. Nine California dental clinics serving low-income and uninsured populations participated. Clinics varied by type (federally qualified health centers, public health clinics, nonprofit clinics), size and structure (mobile, single-site, multi-site), setting (urban and rural), tenure (start-up and more established practices), and patient mix (serving primarily adults or primarily children). Five of the clinics were recruited by CHCF through a formal application process. Clinics were selected for participation based on four criteria: (1) demonstrated community need for greater access to oral health care, (2) willingness to participate in all phases of the assessment, implementation, and evaluation process, (3) evidence of support for participation from executive and clinical leadership, and (4) demonstrated need to Exhibit 1: Participating Clinics Clinic Sponsor Consultant improve fiscal operations. The California Pipeline Program recruited the remaining four clinics from their community clinic partners. Clinics were selected for SCDP participation based on Clinicas de Salud del Pueblo Community Oral Health Services County of Marin Dental Clinic Del Norte Clinics, Oroville Inland Behavioral & Health Services CHCF CHCF CHCF Pipeline CHCF SNS SNS SNS Pride SNS interest and the need to improve clinic La Clínica de la Raza Pipeline Pride management and fiscal capacity. Mission Community Hospital Pipeline SNS Management consulting providers. Over the course of one year, the nine clinics received practice management consulting Native American Health Center Vista Community Clinic Pipeline CHCF SNS SNS 6 The California Pipeline Program is funded by the Robert Wood Johnson Foundation and the California Endowment and administered by the University of the Pacific. Prepared by Harder+Company for the California HealthCare Foundation January

11 from one of two consulting groups: Safety Net Solutions and Pride Institute (Exhibit 1). Safety Net Solutions (SNS) is a program of Dentaquest Institute, a Massachusetts-based oral health organization, that specializes in providing practice management consulting to safety net dental clinics. SNS s approach can be summarized as follows: (1) diagnostic assessment based on analysis of practice data, (2) discussion of findings with clinic staff, (3) development of an improvement plan, and (4) supported implementation of improvement strategies. SNS worked with seven of the nine participating clinics. Pride Institute is a California-based consulting firm that provides practice management consulting primarily to private dental practices. Pride uses a two-year consulting model: the first year focuses on information gathering and systems building, and the second year focuses on implementation. Pride modified their approach for SCDP s one-year duration. The approach includes: (1) diagnostic assessment and creation of vision based on a site visit, (2) a one-day course based on the findings and vision, (3) self-directed implementation based on the new vision, and (4) ongoing consultant support via phone and periodic visits. Pride worked with two of the participating clinics. Evaluating the Success of SCDP The goal of SCDP is to understand the potential of practice management consulting in strengthening community dental practices statewide. Harder+Company Community Research, a California-based consulting firm specializing in research and planning for the health and social service sectors, was commissioned to conduct an independent evaluation of the pilot. The evaluation addressed the following questions identified by CHCF and the California Pipeline Program: 1. What kinds of organizational changes have been made at the pilot sites as a result of participating in practice management consulting? 2. How successful are the nine pilot community dental practices in improving efficiency according to key practice-related measures related to clinical and financial productivity (such as net revenue, expenses, number of visits, wait time to next available appointment, and noshow rate)? 3. How successful are the practice management consulting models delivered to the community dental practices? 4. What are the long-term prospects for implementing the practice management consulting model for safety net dental clinics throughout California? Practice management consulting is designed to improve clinical productivity and financial viability within dental practices, thereby strengthening their capacity and long-term sustainability. However, safety net dental clinics operate within a larger context comprised of factors at multiple levels. Harder+Company developed a conceptual framework (Exhibit 2) that maps the influence of practice management consulting within this larger context. This framework informed the study design as well as interpretation of findings. Safety net dental practices are influenced not only by internal management practices, but also by factors at the health care organization and health care system levels. Clinics operate within a larger Prepared by Harder+Company for the California HealthCare Foundation January

12 health care organization such as a federally qualified health center (FQHC), a county health clinic, or a nonprofit. These health care organizations in turn operate within a larger system of health care resources, policies, actors, and institutions. Practice management consulting targets practice-level factors such as patient policies, scheduling, and billing procedures. While practice management consulting may influence some organization-level factors such as executive leadership and support, it cannot reach factors at the systems and economy levels. The goal of this discussion is not to minimize the potential of practice management consulting in improving long-term sustainability, but to recognize that sustainability is a result of action and change at multiple levels. Each clinic operates within a unique set of constraints and supports at each level, and therefore the outcomes of practice management consulting may be varied. Exhibit 2: Clinic capacity and sustainability are influenced by factors at multiple levels Economy Practice level factors Policies and procedures, operational efficiency, director and line staff support. Health Care System Health Care Organization Dental Practice Organization level factors Patient population, executive leadership and support for oral health as a priority. Systems level factors Policies prioritizing community oral health as a medical need, leadership and networks between community oral health partners. Economy level factors Availability of public and private funding to subsidize cost of care. A Fine Balance: Tradeoffs between Mission and Margin Safety net clinics are defined by a common mission: to provide health care services to individuals and their families regardless of a patient s ability to pay. 7 Safety net clinics have, therefore, a double bottom-line. Long-term sustainability requires a fine balance between mission and financial viability. Restrictive reimbursement structures and tough economic times have forced some clinics to make decisions that are not necessarily reflective of their own values or the interest of public health. It is within this uncomfortable reality that SCDP operates and this reality that SCDP seeks to alleviate. Research Methods The findings of this report are primarily based on a deep analysis of qualitative data using a multi-case study design. The evaluation team conducted a structured analysis of qualitative and quantitative data from nine SCDP clinics (see Appendices A and B) to examine cross-cutting themes, as well as situational influences and constraints. Data included: (1) site visits incorporating in-person interviews with dental practice directors, clinic staff, and clinic leadership at project launch, (2) telephone 7 California HealthCare Foundation. California s Safety Net Clinics: A Primer, Prepared by Harder+Company for the California HealthCare Foundation January

13 interviews with dental directors (or other key staff member) at project completion, (3) review of documents generated through the consulting process (i.e., practice assessments, clinic enhancement plans, progress reports, and final reports provided by the consultants), (4) interviews with the consultants, and (5) quarterly quantitative measures specific to each clinic s dental practice. With respect to item (5), clinics provided quarterly data specific to their dental practice at baseline and for the following three quarters. Measures included net revenue, expenses, patient mix, payer mix, and productivity. While the case study analysis provides a glimpse into what happened and how it happened, quantitative measures add an important dimension by speaking to the degree of change. These measures are central to understanding changes in financial viability and clinic productivity. To understand the model s long-term prospects (Question 4), the cross-case analysis was supplemented by interviews with CHCF and California Pipeline Program staff, potential partnering agencies and other stakeholders, and dental clinics outside of the demonstration project. These interviews went beyond the experience and results of pilot sites to examine the perspectives of key stakeholders. All told, more than 60 interviews informed this report. The full list of interview participants is available in Appendix E. As with any evaluation, certain study limitations must be considered when interpreting findings. The qualitative nature of the study, the clinic selection process, the small sample size, and variation in participating clinics prevent the generalization of findings to the larger population of California community health dental practices. A number of factors influence clinic operations and outcomes, making it impossible to isolate the influence of practice management consulting in the context of this study. Two areas in particular merit specific discussion. 1. At the start of SCDP, the recession and statewide fiscal crisis were already in full swing and some clinics had already set a number of changes in motion prior to SCDP. While the consultant may have facilitated substantial change at some clinics, the impact is less clear at others even from the clinic s own perspective. 2. Also, two clinics (County of Marin Dental Services and Del Norte Clinics) experienced a change in dental director during the project. The leadership change not only disrupted the consulting work, but also created a gap in knowledge and data. While practice measures add an important dimension to the evaluation, they are not the primary determinant of success. Three important limitations exist: 1. It can take a year (and often longer) before implemented improvements are fully reflected in performance data. The final practice measures reported for SCDP reflect only three quarters of implementation time. 2. Clinics reported practice measures to the best of their ability based on their patient records and billing systems. However, data quality may vary from clinic to clinic depending on how easily customized reports can be created and the time lags between service date and payer reimbursement date. Prepared by Harder+Company for the California HealthCare Foundation January

14 3. Baseline net revenue data for Native American Health Center was unavailable. As a result, net revenue analyses for Native American Health Center compare first and third quarters of implementation rather than baseline and third quarter. 4. Practice measures were unavailable for two of the nine clinics Del Norte Clinics and La Clínica de la Raza. Assessment of success relied primarily on qualitative data for these two clinics. In spite of these limitations, the evaluation team believes this study provides valuable insights regarding the potential efficacy of practice management consulting as a strategy for mitigating current challenges faced by safety net dental practices, the strengths and weaknesses of the consulting model, and long-term prospects for such a model. Prepared by Harder+Company for the California HealthCare Foundation January

15 2. Participating Clinics Nine safety net dental clinics throughout California were chosen to participate in the Strengthening Community Dental Practices (SCDP) demonstration. This section provides an overview of these nine clinics, which were selected to represent the diversity of clinics across California. Appendices A and B provide more detailed information on clinic type and size, patient mix, baseline practice measures, and payer mix. Clinic type. Six of the clinics are FQHCs. Due to their focus on serving high-need communities, FQHCs receive higher reimbursement rates under Medi-Cal than other safety net dental clinics. Three clinics fall outside of the FQHC category County of Marin Dental Services (CMDS) is a county-funded public clinic, Mission Community Hospital Dental Clinic (Mission) is a hospitalaffiliated nonprofit clinic, and Community Oral Health Services (COHS) is a nonprofit mobile dental clinic. These clinics receive substantial funding from county government, private foundations, and program grants respectively. Mission and COHS were particularly hard-hit by losses in grant funding, and may face a harder and longer journey to financial viability. Clinic size and structure. The nine participating clinics are diverse in terms of both size and structure. At the smaller end of the spectrum is COHS, the only mobile dental clinic in the group. On the other end of the spectrum, Clinicas de Salud del Pueblo (Clinicas de Salud) encompasses three participating sites, fourteen operatories, and five FTE dentists on staff. All other clinics fall in between in terms of size. While there are additional multi-site clinics in the group, Clinicas de Salud is the only clinic with more than one site participating in the study. Other clinics chose one site to be the focal point with hopes of later adopting successful practices at other sites. Setting. Clinics are located in different regions and represent rural (Brawley, Monterey County, Yuba City) and urban (Oakland, San Bernardino, San Fernando, San Francisco, San Rafael, Vista) practices. Tenure. While most of the participating dental practices are well-established, two practices are relatively new Vista Community Clinic (Vista) and COHS. For over thirty 30 years, Vista has provided a wide range of medical services, but only recently started its dental program. COHS similarly found itself in new territory. Founded with a primary focus in prevention and oral health education, the budget crisis has forced it to move to a revenue-generating, treatment-focused model. Payer mix. For many of the clinics, SCDP started just in time. Six of the nine clinics mostly served adults and faced significant funding difficulties due to the elimination of Medi-Cal adult dental coverage. These clinics looked to practice management consulting to cope with a difficult financial situation and help build a stronger foundation for financial stability. This summary highlights the uniqueness of individual clinics. Despite variation, common across all clinics was their dedication to providing quality dental care to low-income communities. Prepared by Harder+Company for the California HealthCare Foundation January

16 3. Implementation and Results The goal of the Strengthening Community Dental Practices (SCDP) demonstration is to help clinics build a foundation for long-term financial solvency. This chapter describes the overall success of practice management consulting, clinic satisfaction with consulting services, and strategies that have facilitated the greatest strides toward financial viability. The experience of individual clinics can be found in the case studies in Appendix A, and summary tables of these experiences are available in Appendices B and C. Overall Success of Practice Management Consulting Each of the nine demonstration clinics faces unique challenges and limitations in its daily operations. For the purposes of this evaluation, success is defined as the added value of consulting services to clinic operations. In other words, this evaluation does not aim to assess the clinic, but the effectivenessness of practice management consulting on clinic operations. While the available data does not permit a rigorous comparison across clinics, 9 Exhibit 3 provides a helpful framework that ranks relative success based on a review of clinic staff interviews and self-reported financial and operational measures. Three of the clinics realized a high degree of success, three experienced moderate success, and three experienced low success with practice management consulting. Clinic success is ranked along four dimensions: (1) breadth of implementation, or the degree to which clinics implemented the consultant s recommendations, (2) financial improvements (e.g., changes in revenue, patient load, or patient mix), (3) operational improvements as indicated by no-show rate, wait time for appointments, and clinic staff reports, and (4) anticipated longevity of improvements over time. With regard to the last dimension, improvements were judged as long-lasting only if clinic staff buy-in was high and improvements aligned closely with clinic mission and values. Exhibit 3: Assessment of Consulting Success Overall Breadth of Improved Changes to Longevity Clinic Success Implementation Finances* Operations of Improvements Vista Community Clinic High High High High High Community Oral Health High High High High Moderate Services Inland Behavioral & Health High High Moderate High High Services County of Marin Dental Moderate Moderate High Moderate Moderate Services Mission Community Hospital Moderate Moderate Moderate Moderate Moderate Native American Health Moderate High Low Moderate High Center Clinicas de Salud del Pueblo Low Moderate Low Moderate Low Del Norte Clinics Low Low Low Moderate Low La Clínica de la Raza Low Low Low Moderate Low * All financial calculations exclude grant funding. A more detailed discussion is available on page 9. 9 Available data includes interviews with key informants at two points in time and quarterly practice-related measures. While consistent with standard practices in evaluation, the available data only captures snapshots in time with select informants. Prepared by Harder+Company for the California HealthCare Foundation January

17 Financial Viability Beyond Net Revenue and Margin As illustrated in Exhibit 2, safety net dental clinics operate within multiple tiers of constraint and influence. In particular, it is difficult to isolate the effect of practice management consulting from the effects of a fiscal crisis. For some clinics, success may take the form of a tangible improvement in the margin between the dental clinic s net revenue and expenses ( margin ). For others, holding steady may be a significant feat in itself since patients are losing dental coverage and therefore require subsidized care. The rationale behind each clinic s Improved Finances score in Exhibit 3 is described below, including a detailed comparison between clinic-reported measures at baseline and after three quarters of implementation. Vista Community Clinics scored high for raising the margin from -$42,131 to $118,464, which was a result of increased net revenue coupled with reduced expenses. Expense reduction was quite a success given the growth Vista experienced in patient visits (23 percent). Community Oral Health Services scored high for improving their margin from -$113,181 to -$91,516 despite having to transition from a prevention and education clinic to a treatment clinic. COHS also increased their patient visit count by 29 percent. Inland Behavioral & Health Services experienced a margin decline from -$34,776 to -$63,516. Although this would have scored as low financial improvement, IBHS scored moderate due to the increasing proportion of self-pay patients (19 percentage-point increase). County of Marin Dental Services scored high due to reduced expenses and increases in selfpay patients. CMDS s margin improved from -$595,016 to -$335,979 despite fewer patient visits and a patient population that is primarily self-pay (20 percentage-point increase). The clinic was able to reduce expenses in anticipation of drops in patient visits. Mission Community Hospital experienced a decline in margin from -$21,355 to -$27,193 despite growth in patient visits and revenue. This was due to expenses that grew faster than revenue. Mission scored moderate for being able to hold steady with a very large population of self-pay patients (88 percent, a one percentage-point increase). Native American Health Center scored low for the significant decline in margin from $56,008* to -$188,193 due to operating expenses that rose more than net revenue. The clinic experienced growth in patient visits (17 percent growth) as well as self-pay patients (13 percentage-point increase compared to baseline). Clinicas de Salud del Pueblo scored low because the clinic experienced increased losses, with the margin declining from $80,260 to -$30,749. Net revenue decreased quite a bit due to fewer patient visits, but margin suffered because expenses remained unchanged. * Baseline (Q0) net revenue for Native American Health Center is unavailable. Therefore, the baseline margin reported is from the first quarter of implementation (Q1). All other measures reported are from baseline (Q0). Prepared by Harder+Company for the California HealthCare Foundation January

18 To shed light on how clinic experiences vary across domains, examples of clinics experiencing high, moderate, and low success with practice management consulting are described below: High success case. As a newly established clinic, Vista looked to consultants for guidance on how to create an organized, efficient, and financially stable clinic. With support from the executive director and clinic staff, Vista adopted nearly all of the consultant s recommendations to strengthen their foundation for the future. By the end of the engagement, Vista lifted clinic finances out of the red and cut its no-show rate from 41 percent to 20 percent. Moderate success case. As a clinic founded to be the safety net of safety nets for uninsured adults, Mission relied heavily on private foundation funding. Mission s funding deteriorated with the downturn of the economy, and the clinic turned to practice management consulting to streamline operations and strengthen financial viability. As a result, Mission realized success in implementing new fee schedules and scheduling practices. However, many of the consultant s recommendations were not implemented due to conflicts with the clinic s mission and purpose. Low success case. Although Clinicas de Salud implemented many of the recommendations, the clinic did not experience as much success. Clinicas de Salud s main focus was to improve scheduling, which has been a source of significant frustration for staff at all levels. Despite high hopes, Clinicas de Salud experienced significant drops in productivity after implementing new scheduling practices, leading them to go back to past ways of doing business. Satisfaction with Consulting Despite varying success rates, all nine clinics reported satisfaction with the consulting services they received through SCDP. The one clinic expressing the least satisfaction ( somewhat satisfied ) discontinued their involvement with SCDP half-way through the project year due to changes in dental leadership. Clinics reporting lower levels of satisfaction often did not have certain success factors in place, such as internal champions for the work and buy-in from clinic staff and management. Exhibit 4 summarizes overall success, satisfaction, and key challenges as reported by each clinic. Exhibit 4: Clinic Success, Satisfaction, and Challenges Clinic Overall Success Satisfaction Challenges Vista Community Clinic High Very satisfied Would have liked more customization to maximize potential Community Oral Health Services Inland Behavioral & Health Services County of Marin Dental Services High Very satisfied Overhaul in scope of service from prevention to treatment High Very satisfied None reported Moderate Very satisfied Goal for project unclear Mission Community Hospital Moderate Satisfied Did not feel their mission to serve adults was thoroughly understood Native American Health Center Moderate Very satisfied Internal resistance to change from executive administration Clinicas de Salud del Pueblo Low Very satisfied Frustration with scheduling practices, high anxiety in a tough economy Del Norte Clinics Low Somewhat satisfied Needed strong champion and buy-in La Clínica de la Raza Low Satisfied Needed strong champion and buy-in Prepared by Harder+Company for the California HealthCare Foundation January

19 Strategies for Clinic Impact Of the many strategies recommended by the consultants, four areas seemed to help clinics make the greatest strides toward sustainability. These included adjusting fee schedules, modifying patient mix, altering scheduling practices, and establishing policies and procedures. The first two strategies helped many of the clinics increase revenue, while the latter two were commonly used to improve operational efficiency. The results across the nine demonstration clinics indicate that there is no one-size-fits-all recipe for success, and what worked well for some clinics did not work well for others. The unique qualities and characteristics of each clinic therefore necessitate a more tailored approach. In each of the strategy areas, it is important to recognize that some people benefit from changes, and others do not. When clinics increase fees, some patients must pay more for services. When clinics elect to enforce a no-show policy, patients may have to wait longer for care. These are just some of the tradeoffs with which clinics struggle in order to keep their doors open and maintain services for underserved populations. Adjusting Fee Schedules In their mission to serve low-income and uninsured patients, many clinics charged fees well below usual rates for their area. Consultants typically suggested fee increases coupled with steeper sliding scales such that patients at the highest tier would pay more while relieving the financial burden for patients at the lowest tier. By collecting higher fees from those more able to afford it, the clinics could provide larger subsidies for patients at the lowest income levels. Five clinics chose to institute new fee schedules: COHS, IBHS, Mission, Native American Health Center (NAHC), and Vista. Although adjustments in fee increases and sliding scales are not the only strategies affecting revenue, Exhibit 5 shows that these five clinics have managed to maintain or increase their net revenue despite cuts to Medi-Cal adult dental benefits. Three clinics in particular reported high success: NAHC, Exhibit 5: Percent Change in Net Revenue Percent Change Baseline Clinic from Baseline Net Revenue* Clinicas de Salud del Pueblo -24% $516,827 Community Oral Health Services +7% $86,709 County of Marin Dental Services -47% $1,154,806 Del Norte Clinics - Unavailable Inland Behavioral & Health Services +7% $127,808 La Clínica de la Raza - Unavailable Mission Community Hospital +5% $44,729 Native American Health Center +8% $370,483** Vista Community Clinic +36% $338,354 * Net revenue excludes grant funding. ** Baseline (Q0) net revenue for Native American Health Center is unavailable. Therefore, the baseline net revenue reported is from the first quarter of implementation (Q1). IBHS and COHS. Together with improvements in billing and collections, the new fee schedules enabled NAHC to eventually triple their cash and insurance collections from $5,000 to $18,000 per month. NAHC was very happy with the results from both financial and community perspectives. Staff members felt that the steeper sliding scale allowed greater access to care for patients at the lowest income levels, although this was achieved at the expense of patients at the higher income levels. Prepared by Harder+Company for the California HealthCare Foundation January

20 At IBHS, educating patients about the value of services proved to be a key strategy for successful implementation. In the past, the clinic experienced a drop in patient volume after increasing fees. With the consultant s help, IBHS was able prevent patient attrition by educating patients on the value of the clinic s services. For example, the cost of a root canal is typically about $1,500 but a patient may only pay $600 due to the clinic s lower prices and sliding scale. Patient education was crucial to keeping patients satisfied despite fee increases. For COHS, the new fee schedules generated similar success, and this clinic felt that the continued loyalty of their patients was a testament to the quality of their services. As their executive director explained, Patients stayed. I m convinced that it s because they feel like they are getting quality services. While fee schedule adjustments proved successful for some clinics, this may not be a viable solution for others. Three clinics struggled with adjusting fee schedules: CMDS, Clinicas de Salud and Mission. As a county clinic, CMDS had greater difficulty adjusting their fee schedules since any fee increases must be approved by Marin s Board of Supervisors and the public. In light of the recent economic downturn, Marin County is considering fee increases but is conflicted because higher fees may turn some patients away. Clinicas de Salud and Mission felt the fee increases and steep sliding scale were not financially viable. Clinicas de Salud did not implement new fee schedules because of their proximity to the Mexican border. They explained that, if faced with higher fees, many patients would opt for the cheaper clinics in Mexico. The clinic administrator at Mission was similarly wary, stating that everybody somehow manages to find a piece of paper that says they fall within that lower income range. As a result, Mission did not implement as steep of a sliding scale as recommended by the consultants. Both Clinicas de Salud and Mission saw fee adjustments as a risky strategy. Modifying Patient Mix Due to significant cuts to adult public dental benefits, consultants advised clinics to give priority to patients with coverage: children and pregnant women. Patient mix modification is a strategy that enables struggling clinics to both maintain financial solvency while meeting the goal of serving uninsured adults. While uninsured adult patients would not be turned away, they may have to wait longer for non-emergent care (up to 30 days at most clinics). Many clinics took this strategy to heart and actively recruited pediatric patients into their practices. However, clinic data reveal that modifying patient mix may not guarantee more patients with dental insurance. Outreach to pediatric patients. Among the seven clinics that were advised to modify patient mix, two clinics (Vista and COHS) were already serving mostly children. One clinic (Mission) chose not to follow this strategy because alternate resources existed for children in their community, but not for adults. As shown in Exhibit 6, many clinics were successful in reaching more pediatric patients. Clinicas de Salud, IBHS, NAHC, and Vista all increased the pediatric patient population in their practices. Most clinics tried to recruit pediatric patients implicitly through their scheduling practices, which will be discussed in the next section. However, some clinics worked proactively to engage pediatric patients by developing new partnerships and starting portable on-site services at schools. IBHS and Del Norte Clinics implemented active outreach to the families in their communities. Prior to SCDP, IBHS already recognized the need to reach out to patients and they began to engage families in the medical clinic waiting room. If a child had not received a dental check-up in the preceding six Prepared by Harder+Company for the California HealthCare Foundation January

21 months, dental clinic staff would have the child come in right away for an exam, time permitting. Del Norte was similarly proactive by participating in local health fairs and assisting with county wellness programs for children. Exhibit 6: Share of Patients under Age % 92% 84% 80% 60% Baseline 45% 46% 35% 44% 45% 38% 33% 3rd Quarter 6% 6% Clinicas de Salud COHS CMDS IBHS Mission NAHC Vista * Data unavailable for Del Norte Clinics and La Clínica de la Raza. NAHC and Vista had plans to create portable on-site services at schools prior to SCDP, and they appreciated SNS s expertise in portable and mobile clinics. NAHC in particular has experienced great success with their portable clinics, expanding access to two zip codes that previously lacked pediatric providers accepting Medi-Cal insurance. NAHC now operates 11 portable clinic sites, with many more in the works. As of March 2010, the new clinics had reached 310 low-income children ages zero to 14. However, portable clinics may not be an appropriate strategy for all clinics since they require significant resources in terms of management and administration. CMDS, for example, operated a mobile clinic in the past, but they have since discontinued mobile services due to challenges in administration. Connection between pediatric patients and public dental coverage. The rationale for reaching out to children is that they are still receiving dental benefits through either Medi-Cal or other public programs such as Healthy Families. However, clinic data in Exhibit 7 suggest that an increase in pediatric patients may not translate into more patients with public dental benefits. Although IBHS and NAHC served more children, fewer of their patients were covered by public dental benefits. Clinicas de Salud s experience was more in line with expectations in that the growing number of children served coincided with an increase in patients with public dental benefits. However, the percentage-point increases were of different magnitude a 15 percentage-point increase in pediatric patients resulted in only a 5 percentage-point growth in patients with public dental benefits. While focusing on pediatric patients may have contributed to greater financial success, the experiences of these three clinics suggest that the effectiveness of the strategy is neither conclusive nor straightforward. Interestingly, Exhibit 7 also shows that self-pay patients have become a larger share of the patient population at five of the seven clinics. At IBHS and NAHC, a drop in patients with public dental benefits coincided with a rise in self-pay patients, a population that typically requires some degree of Prepared by Harder+Company for the California HealthCare Foundation January

22 subsidy. This trend speaks to the significant challenge that clinics face when trying to maintain financial stability during a period of increased demand for subsidized care. Exhibit 7: Patient Mix, Percentage Point Change between Baseline and 3rd Quarter Clinic Patients Under Age 21 Patients with Public Insurance Patients who Self-Pay Clinicas de Salud del Pueblo (+15%) (+5%) (-6%) Community Oral Health Services (-8%) (+3%) (+20%) County of Marin Dental Services (-11%) (-21%) (+1%) Inland Behavioral & Health Services (+6%) (-20%) (+19%) Mission Community Hospital (-0.1%) (+1%) (+1%) Native American Health Center (+11%) (-13%) (+15%) Vista Community Clinic** (+4%) No change No change * Data unavailable for Del Norte Clinics and La Clínica de la Raza. ** In both time periods, 100% of patients served at Vista Community Clinic were covered by public insurance. Exhibit 8 delineates each clinic s patient population by payer. By the end of the consulting engagement, four clinics (Clinicas de Salud, COHS, NAHC, and Vista) were primarily serving patients with public dental benefits and three clinics (CMDS, IBHS, and Mission) were primarily serving selfpay patients. Exhibit 8: Patient Mix by Payer, 3 rd Quarter 100% 78% 78% 88% 70% 53% 57% Public** 38% 42% Self-Pay 16% 17% 6% 9% 5% 11% 1% 1% 24% 6% 0% 0% Commercial Clinicas de Salud COHS CMDS IBHS Mission NAHC Vista * Data unavailable for Del Norte Clinics and La Clínica de la Raza. ** Public includes Medi-Cal, Healthy Families, and other public insurance. Altering Scheduling Practices Though sometimes seen as a peripheral function in clinics, scheduling practices are a cornerstone of clinic efficiency and financial viability. A clinic s schedule sets the pace and flow for clinic staff and determines which patients will have access to services. Scheduling practices have considerable potential to reduce the sense of chaos in daily operations while maximizing the use of each dentist s time, not only with regard to the number of patients served but also to the quality of care provided. Many of the scheduling improvements suggested by consultants were relatively simple. Most clinics easily implemented practices such as eliminating double-booking, scheduling no more than 30 days in Prepared by Harder+Company for the California HealthCare Foundation January

23 advance, and scheduling by operatory rather than by dentist. When applied together, these practices can help clinics streamline provision of care while reducing the number of no-shows, thereby maximizing overall productivity. Exhibit 9 shows that the three clinics (Clinicas de Salud, CMDS, and IBHS) implementing this new policy were able to reduce the average wait time patients experienced in scheduling appointments. However, it must be noted that wait time is determined not only by scheduling policy, but also by the number of people calling to schedule appointments. With cuts to adult public dental benefits, clinics may be less overwhelmed with appointment requests than they were a year ago. Nonetheless, clinic data reveals a promising trend. Exhibit 9: Average Wait Time Clinic Baseline 3 rd Quarter Direction of Change Clinicas de Salud del Pueblo 12 days 4 days Community Oral Health Services 1-7 days 1-7 days No change County of Marin Dental Services 90 days 30 days Inland Behavioral & Health Services 21 days 5 days Mission Community Hospital 30 days days No change Native American Health Center 30 days 30 days No change Vista Community Clinic 16 days for exams; 2 days for urgent care * Data unavailable for Del Norte Clinics and La Clínica de la Raza. 20 days for exams; 1 day for urgent care No change One of the more sophisticated, and frequently recommended, strategies was designated access scheduling. Of the seven clinics that altered their scheduling practices, five attempted this strategy. Designated access scheduling requires the clinic to think strategically about the mix of patients (and hence payers) that best fits clinic service goals and financial needs. For example, a clinic may find that it needs 60 percent of its patients to be covered by public insurance and 10 percent of its patients to be covered by commercial insurance in order to subsidize care for the remaining 30 percent who are uninsured. 10 Front office staff would schedule patients accordingly to ensure that the clinic achieved the designated patient mix. Under designated access scheduling, uninsured adult patients would not be turned away, but may have to wait longer for non-emergent care. In clinics that schedule appointments no more than 30 days in advance, uninsured adults would have to wait a maximum of 30 days for non-emergent care. Uninsured adults requiring emergency care would continue to receive care as soon as possible. Designated access scheduling gives clinics the opportunity to think strategically about how to make ends meet while fulfilling their mission. As one staff member relayed, We re thinking more about [how we] schedule patients. It s creative scheduling for sustainable production. Even so, changes to scheduling can be a struggle for some clinics. Scheduling was a central focus at Clinicas de Salud it was cited as the biggest problem in the clinic and a source of significant frustration to staff at all levels even before SCDP. After trying new scheduling practices for two months, Clinicas de Salud saw a drop in productivity and patients continued to miss appointments. Out of concern for the clinic s sustainability in a tough economy, clinic management and administration decided to cease some of the new scheduling practices. Despite the rough start, 10 California HealthCare Foundation. The Good Practice: Treating Underserved Dental Patients While Staying Afloat Prepared by Harder+Company for the California HealthCare Foundation January

24 Clinicas de Salud s dental director was hopeful that they would have a second chance at implementation after gaining stronger financial footing. Establishing Policies and Procedures Policies and procedures help standardize and bring greater transparency to how staff members respond to patients in daily interactions. Clinics appreciated that consultants were able to identify what was needed, and then bring in policies and procedures that clinics could tailor to their needs. While policies and procedures entail a broad range of strategies, this section focuses on the most noteworthy: no-show policy, triage process, proof of income, follow-up on account receivables, and clarification of internal policies. No-show policy. Six of the clinics implemented no-show policies, which took on slight variations across clinics. No-show policies clearly delineate plans of action for patients who miss their appointments. Patients would be notified of the no-show policy in advance so that they know the consequences of missing an appointment. Delinquent patients are not typically shut out from care, but are either limited to emergency care or inconvenienced because they will only be able to access services by walk-in. 11 Many no-show policies used a three-strikes approach with escalating interventions. For example, patients may receive a verbal warning after one missed appointment, be assessed a fee of $10-$30 after the second missed appointment, and have appointment access taken away after the third missed appointment. In some cases, no fee is assessed but a more formal or sterner warning is issued after the second missed appointment. Some clinics preempt no-shows by asking for a deposit upon the scheduling of their appointment, which would go toward any treatment fees associated with the appointment. Exhibit 10: No-Show Rates 38% 31% 22% 18% 18% 25% 34% 10% 19% 12% 10% 37% 41% 20% Baseline 3rd Quarter Clinicas de Salud COHS CMDS IBHS Mission NAHC Vista * Data unavailable for Del Norte Clinics and La Clínica de la Raza. ** NAHC was not advised to implement a no-show policy at baseline. Though seemingly simple to implement, no-show policies proved to be the most difficult to enforce. Front office staff was often hesitant to enforce no-show policies because they understand that many 11 Patients who receive services by walk-in do not have a prescheduled appointment. Walk-in patients arrive at the clinic in hopes of having a time slot open up due to no-shows or appointments that end early. Prepared by Harder+Company for the California HealthCare Foundation January

25 patients struggle financially and often do not have control over their work schedules. As one staff member explained, With the economy being bad, we are more in demand now, [with people] losing jobs and losing benefits. We are reluctant to turn clients away. Of the six clinics that implemented no-show policies, four experienced challenges in enforcement. Nevertheless, nearly all clinics saw a reduction in no-shows (Exhibit 10). IBHS and Vista experienced the most dramatic drops in noshows, with 24 and 21 percentage-point drops respectively. Triage process for walk-ins. Five clinics implemented a triage process to sort walk-in patients requiring immediate attention from those who could be seen at a later date. This strategy reduces the incidence of jam-packed waiting rooms and the stress of having to rush from one patient to another. CMDS touted this as the most successful change that has enabled their clinic to run more smoothly. IBHS experienced similar success with triaging walk-ins, and was relieved to know that they did not have to see all walk-in patients immediately. Proof of income. To inform sliding scale fees, consultants recommended that clinics require patients to provide proof of income. Of the five clinics advised to adopt this policy, four chose to implement it. CMDS disagreed with the policy: We see people who are undocumented and homeless [Requiring a proof of income] creates a barrier to services and that is not something we do at other [Marin County] clinics. We rely on patient self-declaration and we take their word for it. Improvements to accounts receivable procedures: collection and follow-up. Three clinics were advised to improve their accounts receivable procedures, which were streamlined to ensure receipt of payments. Improved accounts receivable procedures, together with the abovementioned strategies, enabled NAHC to triple their monthly revenue. COHS experienced similar success, with a 60 percent increase in collections as a result of adopting an electronic billing system. Clinicas de Salud appreciated consultants help in addressing this sensitive issue with patients, stating, Patient care policy made a big difference. [It] helped our receptionist know how to collect from our patients who for years did not have to [pay for their services]. Clarification of internal policies. One clinic, La Clínica de la Raza, focused on building a stronger foundation for change by clarifying internal policies a change that was highly appreciated by staff members at all levels. With the consultant s guidance, the clinic developed clearer policies regarding staff member responsibilities, billing, and management practices. Additionally, the consultant advised La Clínica de la Raza to allocate more hours for staff meetings and set aside more time to address the clinic s administrative needs. Prepared by Harder+Company for the California HealthCare Foundation January

26 4. Consulting Model Practice management consulting is a relatively new model for strengthening the financial viability of safety net dental practices. SCDP has shown that the results of practice management consulting may vary across clinics, as shown in Exhibit 3 in Chapter 3. Three clinics experienced high success, three experienced moderate success, and three experienced low success with the consulting services. The experiences of the nine clinics point to several factors that create an environment for success. By understanding these factors and addressing them prior to the engagement, clinics may experience greater and more predictable success with practice management consulting. This section identifies strengths and weaknesses of the consulting model implemented by SNS and Pride Institute. It also identifies factors that can impede or facilitate successful implementation of the model. Strengths and Weaknesses of the Consulting Model The two practice management consulting firms, SNS and Pride Institute, bring different backgrounds and consulting models to Strengthening Community Dental Practices (SCDP) demonstration. SNS s model is rooted in their consultants deep experience in community dental practice, and they work with clinics to implement specific operational improvements. By contrast, Pride Institute s model is rooted in clinic education, organizational development, and culture change. Pride Institute consultants work with clinics to develop a vision, and rely on the self-direction of clinic leadership to implement changes. Despite differences in approach, the consultants recommendations were similar across the nine clinics. Nonetheless, clinics walked away with varying levels of success at the end of the process. Findings suggest that practice management consulting works best when the consultant brings a deep understanding of safety net dental practice, approaches the engagement as a collaborative partnership, and provides tailored recommendations. Consultant Experience Deep knowledge and experience in safety net dental clinics is clearly one factor that enables consultants to have a positive impact. Safety net dental clinics operate under legal mandates and strict reimbursement guidelines. Consultants with a limited understanding of these mandates and reimbursement structures will not be as effective in helping clinics and risk losing credibility with clinic staff. For example, La Clínica de la Raza s consultant recommended that they include plaque control instruction in appointments for treatment rather than scheduling a separate appointment. However, the clinic s federal grant required a dedicated appointment and space for the plaque control class. One staff member commented, Some recommendations did not seem accurate to our clinic and they still tried to push things. Clinic staff preferred recommendations that were practical, and they needed a consultant who understood the limitations faced by community dental practices. Mission appreciated that their consultants have a nonprofit attitude themselves, and a little more of a feeling for community dentistry. So we were pleasantly surprised [The consultants] were quite down to earth and very realistic about what could and could not be done. Prepared by Harder+Company for the California HealthCare Foundation January

27 Clinic Engagement Approach The more successful clinics felt that the consultants listened to their needs and approached them as partners in the engagement. IBHS, in particular, attributed their success to SNS s collaborative style in working with them. According to their health administrator, They worked with us to develop recommendations and strategies. They didn t tell us what to do. It was a collaborative effort and they spoke with authority, knowledge, and experience. SNS worked closely with IBHS staff to develop goals and strategies, and got them on board with the recommendations early on. Consultants who view the engagement as a collaborative partnership were able to gain greater buy-in and therefore achieved greater follow-through in implementation. As IBHS s dental director explained, Everyone s a little resistant to change I think, so you need to sell the changes. You can t just say we re going to do things differently it s important to let them know why and what [the clinic] can expect from it. If you do that, and do it correctly, I don t think there s a problem with anybody accepting any of the changes. IBHS s experience differed greatly from that of Del Norte Clinics, who discontinued their involvement with the project half-way through. Although this was partly due to the dental director s departure, clinic buy-in was minimal from the start. Having buy-in from the start of the process perhaps would have motivated them to continue on regardless of this transition. At Del Norte Clinics, staff felt that the consultants tended to focus on their weaknesses, stating, Staff would have been more receptive if they had approached us in terms of helping us versus fixing us. Customization of Recommendations While the consultants recommendations resonated with most clinics, two clinics (Mission and Vista) suggested there would have been deeper change if the recommendations were more customized. Financial viability beyond serving more children. Mission implemented many of the recommendations, but realized fewer improvements financially due to their intentional focus on adult dentistry. Their clinic administrator expressed, The reason this clinic exists in the first place is that one of the foundations here in California teamed up with Mission Community Hospital to increase access to adult dentistry, which is one of the major health issues in this community. Mission also faced some practical limitations that impacted their ability to serve children. As a sitebased practice relying on portable equipment, Mission s chairs and equipment were not designed for pediatric patients. Furthermore, as a clinic with only three chairs, it would not be possible to crosssubsidize adult dental care through pediatric patients. They said if you see [a certain] number of kids, you can slip a few adults in. I told them up front that while it may look good on paper, but it won t necessarily translate. Here, first of all, with our equipment issues, we re not necessarily set up to be a pediatric practice [Although] we could increase the number of children we see, but we cannot do it to the extent that SNS suggests nowhere near 65 percent of our practice [because our clinic is not very large]. Clinics starting with above-average productivity. At the start of the project, six of the nine demonstration clinics were already exceeding benchmarks set by the Health Resources and Services Administration (HRSA), an indicator that the clinics may be overworked. The benchmarks suggest Prepared by Harder+Company for the California HealthCare Foundation January

28 that an average clinic produces at a rate of 2,500-3,200 visits per FTE dentist per year, while many of the demonstration clinics produced at rates of 4,000-5,000 visits per FTE dentist per year. Aboveaverage productivity raises questions about quality of care and patient experience issues that consultants recommended clinics to re-evaluate. However, clinic staff members expressed that they still felt pressure to push for greater productivity. Vista produced at a rate of 4,926 visits per FTE dentist per year at the start of SCDP. Their dental director expressed concern that they were not working toward a more manageable workload. We were all thinking that they would say, Hey you guys are really working too hard, let s reduce it, and of course that is not the way it goes. That is what the staff and doctors wanted but that s just not the way it s going, she said. With an average productivity rate of 3,888 visits per FTE dentist per year, La Clínica de la Raza also had concerns about low staff morale. As the associate dental director explained, We re worked to the maximum due to [the clinic s] disorganization and problems that don t really need to be [that way]. The experiences of these clinics indicate that reducing productivity is not a simple task. Reducing productivity in the interest of quality of care would require a significant push by clinic staff and consultants. Opportunities to push for further improvement. Vista had great success with implementing SNS s recommendations. In fact, they completed their recommendations within 90 days of receiving them. Vista staff expressed disappointment, however, in the level of customization in the recommendations. [The recommendations] could have been a little bit more specialized for our clinic, suggested Vista s dental director. I don t know if they were working with too many clinics at the same time It was hard for them to really focus on what was going on with our clinic rather than having a generic plan Some of the things they were suggesting were things we were already doing. It wasn t customized. Factors that Influenced Success From the experiences of the nine pilot clinics, several themes arise as requisite factors of a successful consulting engagement. Clinics with the requisite factors in place may experience greater and more predictable success with practice management consulting. Exhibit 11 outlines six success factors as well as key questions to consider for each. Exhibit 11: Factors that Influenced Success Factors Key Questions Buy-in at executive (CEO, CFO, COO) and clinic levels Is the clinic administration committed to providing leadership, resources, and other support for the work? Are staff members ready and willing to change existing practices? Clear and compelling goals A culture that supports change Does everyone at both the administrative and clinic levels understand the project goals? Clear, compelling goals should portray: A shared vision for change. A sense of urgency for change. Clear benefits for patients, administration, and staff members. Are staff members encouraged to speak up, raise new ideas, and try new things? Does this culture exist at both the administrative and clinic levels? Prepared by Harder+Company for the California HealthCare Foundation January

29 Factors Project champions Availability of resources Consultation customized to clinic needs Key Questions Are there project champions at both administrative and clinic levels that will lead the work, and advocate for the support and resources necessary for success? Are existing resources, including technological resources and facilities, adequate to support change? Will the dental director, clinic manager, or other leaders have release time to work on change? Which issues are at the core of the clinic s needs? What should be the role of practice management consulting in helping the clinic move forward? Buy-in from executive leadership and clinic staff. Buy-in is defined as a strong sense of ownership in the project and a drive to advocate for greater change. It is critical that the executive leadership of the health care center is fully committed to the project and will provide the leadership, resources, and support necessary for successful implementation. Dental directors and managers at the nine pilot clinics often expressed concern that the executive leadership may not support change. Executive buyin is critical because it creates a supportive environment and signals an openness to change throughout the organization. Buy-in from front-line staff is also essential because they are responsible for implementing changes on a day-to-day basis. In some cases, lack of support of front-line clinic staff proved to be a considerable barrier to success. Front-line staff expressed that they welcomed change and were excited about the improvements. Nonetheless, many felt anxious about the process, questioning the organization s motivation for hiring consultants and challenging the validity of the recommendations. A closer look at the data reveals that clinic staff buy-in was frequently incomplete. As a result, the consulting project was not seen as a priority and relatively little change occurred. At times, clinics would implement new policies but find that enforcement was inconsistent. Exhibit 12 describes level of buy-in from clinic staff and executive leadership. Exhibit 12: Clinic Buy-in and Project Champions Clinic Overall Success Line Staff Buy-in Executive Buy-in Clinic Champion Executive Champion Vista Community Clinic High High High Yes Yes Community Oral Health Services High High High Yes Yes Inland Behavioral & Health Services High High High Yes Yes County of Marin Dental Services Moderate Medium Medium No No Mission Community Hospital Moderate Medium Medium Yes No Native American Health Center Moderate High Low Yes No Clinicas de Salud del Pueblo Low Low Medium Yes Yes Del Norte Clinics Low Low Medium No No La Clínica de la Raza Low Medium Medium No No Project champions. An essential contributor to project buy-in is the existence of strong leaders at the administrative and clinic levels who serve as the internal champions for the work. At the executive level, the project champion should be able to effectively communicate progress and obtain resources. At the clinic level, the project champion plays a pivotal role by inspiring staff to maintain focus on the task at hand. Successful clinic-level champions have earned the trust of front-line staff and gained a Prepared by Harder+Company for the California HealthCare Foundation January

30 deep understanding of day-to-day operations. Furthermore, they are well-positioned to communicate clinic concerns upward to the executive leadership. Most often, the project champion is an individual who has a history with the clinic and understands what is needed to gain buy-in and create change. The less successful demonstration clinics had champions who lacked close involvement with groundlevel operations. At La Clínica de la Raza and Del Norte Clinics, there was minimal buy-in amongst the managers who oversaw day-to-day clinic operations. This created problems because project goals were unclear to the very staff members tasked with implementation, many of whom were wary of the changes. The most successful clinics had a strong project champion who was involved with all phases of the consulting project, from planning through implementation. At La Clínica de la Raza, the associate dental director lamented that the clinic would have taken greater advantage of the consulting services if she had known more about what the project was about and had time to think about [their] shortcomings and what [they d] want out of consulting. A culture that supports change. Cultural norms at the executive and clinic levels can either support or inhibit change. These norms go beyond resources and support, and are influenced by the executive administration. Cultural norms dictate whether change and innovative thinking are nurtured rather than stifled. In a culture that supports change, staff members feel safe and encouraged to speak up, raise new ideas, and try new things. Without it, staff members feel hesitant to suggest new ideas or try new practices for fear of failure and blame. In clinics that experienced greater success, staff at all levels understood the urgent need for change and were very open to the consultant s suggestions. COHS and IBHS were highly motivated because they saw a need for change. COHS looked to practice management consulting for guidance on how to cope with a substantial loss in grant funding. As the executive director explained, If we don t turn this ship around, there won t be any services provided by COHS. It s that serious of a situation. We will either correct this, or we turn the lights off. IBHS, a clinic that was hit hard by cuts to adult Medi-Cal, understood the need for change in order to maintain long term sustainability. As their management explained, We were ready...there was an internal realization that something s got to change, but what do we need to change? Clear and compelling project goals. Another factor that tended to facilitate or impede success was the clarity and intensity of project goals at the start of the engagement. The goals of the consulting engagement should be clear to everyone involved at the executive and clinic levels. In particular, the goals should portray a shared vision for change, the urgency of change, and the potential benefits it has for patients, administration, and staff members. When goals were clear at the outset, staff members were more likely to understand why changes were needed and maintain focus on the work. With the hectic schedules and high stress levels typical of safety net clinics, clear goals ensured more follow-through in the implementation phase. The stated goals did not need to be grounded in quantitative targets, but they did need to be concrete enough that staff members understood the unifying force behind the work. Clinic goals ranged from billing improvements to general stress reduction to clinic survival. Those who simply wanted a fresh pair of eyes to look at clinic efficiency were less able to take full advantage of the breadth of consulting services available. Prepared by Harder+Company for the California HealthCare Foundation January

31 For example, CMDS had unclear goals for the project but was, on the whole, a high-functioning clinic. CMDS did not have specific project goals, but they sought opportunities for improvement in light of the difficult fiscal environment. Their biggest threat was the new dental clinic at the local FQHC. Prior to SCDP, they had already initiated strategies to turn this competitive threat into a partnership opportunity. Although the consulting engagement appears to have helped CMDS, it is difficult to assess the impact of SCDP. Availability of resources for consulting work. A successful consulting engagement not only requires the dedication and commitment of clinic staff, but also concrete resources in terms of release time for staff members to do the work, data capacity to diagnose and monitor clinic needs, and adequate technological resources and facilities to support change. This is connected to the level commitment and buy-in from the executive leadership at the start of the project. Staff members must have time to do the necessary work, and the clinic must have data capacity to diagnose and monitor the clinic s changing needs. Lasting change requires significant staff time because it entails planning, trial and error, patient education, training, and facilitation of relationships none of which are quick or simple. To realize the full potential of the consulting work, clinics need sufficient data capacity to monitor progress and calibrate new strategies to shifting needs. For example, adjusting fee schedules is not merely a matter of posting a new schedule. It requires discussions with the consultant on what is appropriate based on the patient population in the planning phase, patient education and staff training in the implementation phase, and continual data monitoring to ensure that patient needs are met. Consultation customized to address clinic needs. New and established clinics tend to have varying concerns and barriers to change in the consulting process. New clinics typically seek an infusion of knowledge and expertise. For example, Vista was a longstanding FQHC that recently expanded into dental practice. As a start-up, they had a high level of buy-in and commitment from staff at all levels and faced far less resistance in implementing new policies and ideas. On the other hand, established clinics often needed someone to help them move beyond old habits and adopt improvements. Established clinics can be more difficult because staff members are seldom eager or open to change. Exhibit 13 offers a potential typology for considering clinic needs for change and possible implications for the consulting approach. Exhibit 13: A Potential Typology of Clinic Needs High Stress High Resistance Positioned for Change Clinic attributes Chaotic and stressful clinic operations. Limited staff time and data capacity to participate. Champion sees need for change but faces resistance. Needs third party to help prioritize resources. Well-positioned for change, but needs tools and/or buyin to move forward. Consulting approach Coach. Clinic has minimal culture of change. Help managers see why operations are stressful so they recognize need for change. Facilitator. Clinic is ready to expand culture of change. Extend buy-in to clinic staff and executive leadership to enable implementation. Catalyst. Clinic already has culture of change. Help identify final pieces required to put ideas into action. Case examples Del Norte Clinics, La Clínica de la Raza Clinicas de Salud, Native American Health Center Vista Community Clinics, Inland Behavioral & Health Services Prepared by Harder+Company for the California HealthCare Foundation January

32 Improving the Design of Consulting Model Clinics were asked to identify ways in which SCDP could better respond to their needs. While all clinics expressed satisfaction with their consultants, they did offer three recommendations for consideration. Concentrate on one domain area at a time. Each clinic received a long list of recommendations that typically encompassed all areas of clinic operations including scheduling, billing, internal communications, policies, and provider incentives. One dental director felt that the list was overwhelming and suggested dividing recommendations into modules. The goal would be to make it easier for clinics to focus on deeper change in each domain area rather than scattering efforts across so many diverse areas. Incorporate peer learning opportunities. Many clinics noted that it would be useful to share strategies and successes with other clinics in similar situations. For example, FQHCs of similar size and organizational infrastructure could share strategies on how to phase in policy changes or gain greater buy-in from executive leadership. A program officer of a large California foundation agreed that peer learning opportunities such as group convenings, conferences, and webinars are important. The clinics see themselves as part of a field and part of a movement, she noted. As such, it is appropriate to engage them in that way. Minimize data and reporting burdens. For the demonstration project, clinics were asked to submit monthly progress reports and quarterly data on key practice-based measures. Although clinics understood the need for reporting, they found the process to be burdensome and they noted that the time spent on reporting could have been better spent on implementation. Some clinics reported that they had trouble submitting data for SCDP due to misalignments in the way data was kept and how it needed to be reported, rather than a lack of data capacity at the clinic. Prepared by Harder+Company for the California HealthCare Foundation January

33 5. Considerations for Future Work To more deeply understand future prospects for this approach, the evaluation team conducted supplemental interviews with key stakeholders consisting of oral health care stakeholders, staff of dental clinics outside of the demonstration project, as well as foundations who have an interest in oral health care. Key informants were asked to comment on a number of topics including: (1) need and interest for practice management consulting among safety net dental practices, (2) practice management model as a method of strengthening safety net dental practices, and (3) prospects for future implementation. This section of the report summarizes findings from these key stakeholder interviews and highlights considerations for future work in this area. The full list of interview participants is available in Appendix E. Clinic Desire and Need for Practice Management Consulting Key stakeholders reported that there is definitely a need for practice management consulting among safety net dental clinics. One participant shared, There is definitely some need.[clinics are] just too overwhelmed to be strategizing about that sort of thing, so it s definitely valuable. However, clinic resources for this type of assistance remain elusive, especially in light of the current economy. One respondent felt that [there are] no resources. That s what makes this project important and unique. There is not enough assistance or training [for clinic staff]. The majority of clinics interviewed agreed that there is a desire and need for practice management consulting, but obstacles to participation exist the time and effort required for participation as well as potential resistance from clinic leadership. Currently, the greatest challenge for many clinics is survival in a tough economy. With their resources stretched so thinly, clinics may be hesitant to participate. Resources, particularly financial resources, are hard to come by for safety net dental clinics. The key would be to convince executive leadership of the return on investment. One individual explained, If you can make the case that it will help their bottom line, absolutely [they will do it]. That s what it s all about to the CEOs the bottom line. Others noted that having a sliding scale for consulting fees may be more realistic given budget constraints clinics are currently facing. Potential of Practice Management Approaches Overall, oral health stakeholders believe that practice management consulting holds significant promise for strengthening a clinic s long-term sustainability. Participants noted, however, that the model does have its limitations. Consistent with the findings of this report, they noted the importance of designated project champions at the executive and clinic levels, buy-in from staff at all levels, and resources to support the consulting work. Additional concerns expressed by participants include: Clinic recognition of a need for change and the will to move it forward. People are interested in it, it s just whether they can get the political will within their clinic to move forward with it. Scale of expected change. When we look at how we define success on projects like this, it s on an incremental basis. While no-show policies are really important to have, is it going to make them financially viable? No. The efficiencies are important, but I m cautious about managing Prepared by Harder+Company for the California HealthCare Foundation January

34 expectations about what they can do for the overall system We have to remember we re trying to optimize a very suboptimal system. Omits quality of care and prevention. The greater question is how you can support high quality, prevention-oriented services while looking at financial viability. Quality and prevention are important, but there is a tension with financial viability. Treatments and restorations are typically reimbursed at higher rates. Setting the Stage for Success Stakeholders and potential partners were generally positive about the prospects for a program similar to SCDP, and felt much can be done to set the stage for success at the organization and health system levels (abovementioned in Exhibit 2). Below is a summary of their suggestions: Build recognition of a need for change and buy-in for the change process. The oral health community should continue to advocate for the integration and prioritization of dental care into mainstream health care, and also educate health care agencies (FQHCs, nonprofits, county health clinics) on the value of dental practice management consulting. These efforts will help health care agencies recognize a need for change, foster a culture that supports the change process, and allocate resources for the consulting work. Capture long-term impact. Practice management consulting promises to build a foundation for long-term sustainability. With the significant costs associated with consulting services (approximately $15,000-$25,000 for one year), it will be important to track progress and assess long-term impact in order to make the case for this type of assistance. Stakeholders each have a role in strengthening safety net dental clinics. Foundations can play a significant role in improving safety net programs by continuing to support practice management consulting. Professional associations or clinic trade groups could potentially serve as intermediaries for this type of work given the role they play in assuring quality and promoting access to care statewide. With the current fiscal environment, stakeholders do not expect to see government agencies providing financial support for such initiatives. However, they believe government could play a role in incentivizing quality of care and productivity. Offer alternative modes of assistance. Practice management consulting is not a cure-all, and some clinics may need alternative modes of assistance to address their needs more directly. For example, clinic managers may need leadership training, the clinic may need help facilitating a strategic planning process, or the billing team may need training in data management. Prepared by Harder+Company for the California HealthCare Foundation January

35 6. Discussion and Recommendations This section of the report offers considerations with regard to optimizing practice management consultation. It outlines success factors with respect to participating clinics, consultants, and the consultation approach. Environment for Success Safety net dental clinics tend to be unique, each with their own assets and challenges. Practice management consulting has the potential to help clinics build a stronger foundation for the future, but it may not be appropriate or successful for all safety net dental clinics. Interventions should be designed and targeted based on clinic and community needs. Determine whether the clinic has the requisite elements of success in place. This demonstration has indicated that several requisite elements of a successful consulting engagement: executive and clinic level buy-in, a culture that supports change, clear and compelling project goals, a designated project champion at both the health center and dental department level, and the availability of resources for the consulting work. A preliminary assessment would set the stage for success by identifying clinics that require support in these areas prior to the consulting engagement. Determine if core concerns are rooted in clinic operations and management. Practice management consulting can help a clinic become more efficient and productive, therefore putting them on the right track toward financial stability. For some clinics, however, core issues may not be rooted in operational efficiency, policies, or procedures. For some, the clinic s mission and purpose are inherently unviable from a financial standpoint, and their concerns are more directly addressed through public policy and systems change rather than operational efficiency. Prioritize participation based on community need. Given limited resources to support clinics, prioritization becomes a significant concern. One potential project partner suggested considering measures of place-based need in the assessment process (e.g., county poverty rate, share of adults who are uninsured, and prevalence of dental emergency department visits). The community characteristics of the pilot clinics are available in Appendix D. Consultant Characteristics The evaluation also identified considerations with respect to the selection of consulting providers including areas of expertise, credibility, collaborative working style, and regional expertise. Look for consultants whose areas of expertise align with clinic needs. Consultants have varying areas of expertise, and it is important to match clinics with consultants that could best address their needs. This consideration is especially relevant for clinics that need support in developing the requisite elements for success identified above. For example, clinics lacking a culture that supports change or organizational buy-in may benefit from consultation in leadership and management, while clinics lacking appropriate IT resources to maintain performance data may benefit from consultation in database development and management. Prepared by Harder+Company for the California HealthCare Foundation January

36 Focus on credibility. Consultant credibility is essential to success. Clinic staff members generally felt that consultants rooted in private practice were a mismatch with community clinics, or conversely that consultants with experience in safety net services were highly valuable to those clinics. Clinics reported greater receptivity to suggestions from a consultant who was also a community dentist. Look for consultants who engage clinics as collaborative partners. Most clinics indicated that the consultants were creative and insightful in their suggestions. Several specifically appreciated that the process had turned out to be a tremendous learning opportunity, with one stating, We are just amazed at all the things we are learning. Another praised the consultants for giving us the facts without sugarcoating and without hurting our feelings. Staff who experienced consultants suggestions as negative exhibited resistance to change. Look for consultants with regional expertise. Some clinics reported challenges in working with an out-of-state provider due to scheduling constraints and limited availability for hands-on assistance. It may be possible to develop in-state expertise on the consulting model through a train-the-trainer model designed to support diffusion of practice management strategies across the state. Consultation Approach Overall, clinics expressed a high level of satisfaction with the consulting work. However, findings also point to potential refinements to the model summarized below. Provide more implementation assistance for clinics that need it. Clinics experiencing high resistance or significant chaos in their daily operations voiced a desire for more assistance with implementation. Although it would be more costly, having consultants assist with implementation may help clinics navigate resistance more effectively and prioritize the work. Account for quality of care and prevention. An inherent tension exists between financial viability and quality of care. Some of the potential partners for this project feel strongly that the consulting approach needs to integrate quality of care and prevention into the clinic setting. As clinics struggle to find the right balance, consultants should appreciate this tension and discuss the possible tradeoffs of each strategy with clients. Seek opportunities to facilitate buy-in. Because of the inherent difficulties in assessing clinic buy-in, consultants should seek out opportunities to develop buy-in through the consulting process. Understanding clinic readiness for change, actively working to develop support from line staff and potential champions, and facilitating convergence among executive and dental staff can increase the chance of success. Explore alternative delivery mechanisms. CHCF and the California Pipeline Program may wish to consider alternative delivery mechanisms (i.e., webinars, in-person group trainings, and conference calls) that would provide access to a larger number of clinics. Overall, findings suggest that clinics benefitted from hands-on assistance. However, it may be possible to design a program that targets different operational areas in separate modules, perhaps with increasing intensity (i.e., from broad low-touch strategies that reach many clinics to individualized high-touch strategies that serve a small set of clinics). Prepared by Harder+Company for the California HealthCare Foundation January

37 Safety net dental clinics strive to maintain a fine balance between upholding their mission and maintaining financial viability. Serving those most in need regardless of ability to pay while also collecting enough revenue to keep clinic doors open can be quite a challenge. It is especially difficult to achieve this balance during a time of declining resources, high unemployment, and growing patient need. The nine demonstration clinics illustrate some of the difficult decisions and uncomfortable tradeoffs that safety net clinics must make. Findings from the evaluation suggest that practice management consulting, while not a cure-all, shows promise for helping clinics achieve a productive balance between their public health missions and fiscal solvency. Prepared by Harder+Company for the California HealthCare Foundation January

38 Appendix A: Clinic Case Studies Case studies are the foundation of the findings of this report. They provide an in-depth look at the successes of each clinic within the context of the fiscal concerns, organization and policies under which it operates. The case studies present structured qualitative analyses of information reported by key clinic staff through interviews, and are organized into four main sections: Clinic background. This section highlights the clinic s key attributes and provides context for understanding the clinic s challenges and goals. Data reported in this section reflect clinic circumstances prior to receiving consulting assistance. Baseline challenges and goals. This section describes the clinic s key challenges at the start of the project and their goals with regard to practice management consulting. Recommendations and outcomes. The section outlines successful recommendations and outcomes reported by the clinic. The narrative describes key recommendations that the clinic highlighted in their interview, while the recommendations box provides a more comprehensive list of what the consultants suggested. Reported outcomes are based on the clinic s general sense of each recommendation s success as well as self-reported practice-based measures. Reflecting on the project. This last section of the case study provides the clinic s own reflections on the engagement as well as Harder+Company s observations as an objective evaluator. Appendices B through D provide at-a-glance summaries of the case studies. Prepared by Harder+Company for the California HealthCare Foundation January

39 Clinicas de Salud del Pueblo Clinicas de Salud del Pueblo (Clinicas de Salud) is the only FQHC in Imperial County and operates sites in Brawley, Calexico and Mecca. 12 Imperial County has a large population of low-income residents, and their patients are comprised of low-income families on Medi-Cal and Healthy Families, homeless individuals, HIVpositive individuals, and other underserved populations. Most of the population is Spanish-speaking, and many are farm workers. Clinicas de Salud serves patients of all ages, but the clinic has seen a drop in adult patients after cuts to Medi-Cal adult dental coverage. To serve the population of the region, the clinic accepts walk-ins, provides evening and Saturday hours, and charges fees that account for varying income levels. Imperial County has a poverty rate of 22 percent, and about 22 percent of the adult population is uninsured. At-A-Glance FQHC with 3 dental clinic sites >24,000 visits/year Brawley: 6 operatories Calexico: 5 operatories Mecca: 3 operatories More than 50% adults 76% Medi-Cal, 6% Self-pay, 14% other public plans Mostly low-income Latino population Consultant: SNS Baseline Challenges and Goals In the face of a budget crisis and the elimination of Medi-Cal adult dental coverage, Clinicas de Salud sought practice management consulting to help them adjust to these tough economic times. As the only FQHC in the county, they wanted to ensure that the clinic remains financially stable and is able to continue serving patients in need. Their central focus in this project is scheduling, which was identified in the past as an area that needed improvement. As expressed by clinic manager, The schedule has been the biggest problem. Clinicas de Salud hoped to reduce its no-show rate and improve scheduling procedures to ensure that chairs are filled and dentists are kept busy. As a clinic that works hard to serve everyone, Clinicas de Salud was producing above benchmarks set by the Health Resources and Services Administration (HRSA). By engaging in practice management consulting, they hoped to reduce the stress of day-to-day operations. Recommendations and Outcomes Staff and executive management saw practice management consulting as a way to keep the dental clinic open just as other clinics in the region were forced to reduce staff or even close down. Their Chief Operating Officer (COO) was hopeful that the consultation would enable them to be far more efficient in [their] way of delivering service to patients. Clinicas de Salud was eager for change and improvement, yet highly wary of how these changes will affect them in a turbulent economy. Although scheduling improvements were a central focus for Clinicas de Salud, many of the changes were abandoned when time slots were left unfilled and productivity dropped. Their most successful changes were around data keeping to monitor daily productivity rates and defining a scope of service. 12 Mecca is just inside Riverside County, on the Imperial County border. Prepared by Harder+Company for the California HealthCare Foundation January

40 Monitoring data collection. SNS recommended that Clinicas de Salud collect financial data on the dental clinics expenses per day and per visit in order to better identify areas with the greatest potential for improvement. Clinicas de Salud found the analysis to be a significant eye-opener for senior management and helped them understand Recommendations each of the three clinics more deeply. More importantly, the collection of data enabled to improvements in clinic organization and management. They can now base decisions about fee schedules and scheduling on concrete data. As their data efforts continue to evolve, Clinicas de Salud expects to track improvements in quality of care through data on treatment plan completion. They plan to continue monitoring quarterly practice-based data even after this project ends. Define scope of service. The clinic s biggest change was the adoption of formal patient care and payment policy. By defining their scope of service, Clinicas de Salud specified which treatments they provide and the fees charged for these treatments. This helped formalize patient care and provided the front office with the information necessary to collect payments from patients. Modify scheduling. To mitigate stress with regard to scheduling and draw in more revenue, SNS made several scheduling recommendations: (1) implement a no-show policy, (2) schedule patients with an eye toward payer mix, (3) eliminate over-booking, (4) reduce the number of daily appointments, (5) stagger scheduling for each operatory. Clinicas de Salud piloted these suggestions at their Brawley clinic, but with poor results. They had to stop enforcing the no-show policy because it resulted in so many open time slots. Patients continued to miss appointments, and they had to do what was necessary based on the financial reality. The nosedive in productivity and finances Fully Implemented Data keeping to monitor and track cost of service per day and per visit Determine scope of services and create tracking mechanisms to document patient treatments Formal procedures to collect patient payments Formal procedures to ensure reimbursement from Medi-Cal Policies for managing self-pay and emergency patients Staff training to conduct patient education on eligibility determination and value of services Schedule out no further than 45 days and give follow-up appointments one at a time Implementation Ongoing Designated access scheduling Increase the number of children and pregnant women by coordinating referrals from the medical side of the FQHC Educate patients about value of services received Create multidisciplinary performance improvement team Improve billing process Standardize clinical protocols Create quarterly reports Reduce number of daily appointments Eliminate over-booking Implementation unsuccessful Staggered scheduling for each operatory Create and enforce no-show policy Self-Reported Outcomes To Date Improved patient flow and clinic productivity Resolved issue with denied Medi-Cal claims Better documentation of patient procedures Reduced no-show rate Increased pediatric patient population Expected Streamlined scheduling Decisions made based on clinic financial data pushed them to abandon the changes after two months. Clinicas de Salud is hopeful that they might be able to try some of these recommendations again when they are more financially stable. Prepared by Harder+Company for the California HealthCare Foundation January

41 Reflecting on the Project The project has completely helped us in knowing what we need to do. As we continue to grow and see patients, it gives us a good blueprint. - Clinicas de Salud Dental Director For Clinicas de Salud, SCDP came just in time to address cuts to Medi-Cal. Clinicas de Salud appreciated the wealth of knowledge and experience SNS had in safety net dentistry. As the Clinicas de Salud dental director explained, From their experience, they were able to convey that they know exactly what we re going through. They were able to provide recommendations and give us realworld probabilities or outcomes. With the current economic climate, Clinicas de Salud found it hard to implement changes despite their desire for it. Staff at all levels wanted to see immediate positive impact, and they were not in a place to think about best practices for the long term. Although Clinicas de Salud could not maintain some of SNS s recommendations, they were glad to have them as a blueprint for the future. In time, Clinicas de Salud hopes to have greater financial stability, which will enable them to work on these recommendations and try new things. As the dental director relayed, The model does work, but it takes time to implement. When asked how SCDP could be improved, the Clinicas de Salud dental director explained he enjoyed attending monthly phone and video conferences, but would have liked to see more opportunities to learn from and collaborate with other clinics. Clinicas de Salud felt that in-person consultations are more impactful because being able to sit down with the consultants and have them right there and tell us what they found and show us [their findings] with a presentation had such a great impact, more than a video or teleconference. Although Clinicas de Salud admits they would not be able to fund further consultation at this time, they feel that the extra cost was worthwhile and would consider it in the future. Without [site visits], we wouldn t have been able to do any change or convey the importance of these changes if it was only handled by phone or . - Clinicas de Salud Dental Director Prepared by Harder+Company for the California HealthCare Foundation January

42 Community Oral Health Services Community Oral Health Services (COHS) is a nonprofit mobile dental clinic based in Monterey County that was initially formed to serve children aged 0-5 and pregnant women in Central California. Primarily funded through First 5 Monterey County, COHS developed a unique oral health program focusing on pediatric care in oral disease prevention, early intervention, education, and outreach. The clinic operates five days per week from two mobile dental vans that rotate between locations in Salinas, Greenfield, King City, and Seaside. COHS dental vans locate in the parking lots of schools and family resource centers. Through their work with children, COHS has also been able to reach out to parents and bolster oral health care for adults. Many of the clinic s patients are on public oral health plans such as Medi-Cal or Healthy Families. The majority of patients are Spanish-speaking and many are families of agricultural migrant workers. Baseline Challenges and Goals COHS was established to augment [the services of community health centers] and to serve as an education and preventative arm that most practices and community health centers were not able or willing to perform. Their services in education and prevention were funded by grants from First 5 of Monterey County, an organization dedicated to the welfare of young children and families. In the wake of the statewide fiscal crisis, COHS faced an 80-percent cut in its grant funding from First 5 of Monterey County and found that it needed to set a new direction in order to survive. As one dentist explained, If we don t turn this ship around, there won t be any services provided by COHS. It s that serious of a situation. We will either correct this, or we turn the lights off. That will affect a tremendous amount of our population. As a clinic that initially focused on early intervention and prevention, it was a challenge for COHS to move toward treatment and restorative care. They were open to change and new ideas because a treatment-based model would require significant changes in the focus, culture, and day-to-day operations of the clinic. Recommendations and Outcomes At-A-Glance Nonprofit, mobile dental clinic serving Monterey County 2 mobile vans 1,947 visits (Aug.-Dec. 2008) More than 95% pediatric patients 49% Medi-Cal; 23% Private Insurance;14% Self-pay 53% revenue is grant-funded Mostly low-income Latino population Consultant: SNS COHS was keenly aware that practice management consulting was an opportunity to obtain the guidance and tools needed for firm footing as a treatment-oriented dental clinic. COHS adopted formal policies and procedures such as fee schedules, policies around emergencies and no-shows, encounter forms, and electronic billing systems. Their executive director expressed that [SNS] gave this organization a little bit of structure that it desperately needed someone to identify the problems and say what to correct, and then put that reality in place. Prepared by Harder+Company for the California HealthCare Foundation January

43 Increase clinic fees. SNS recommended that COHS increase their fees, which were previously quite a bit lower than usual rates for the area. To ensure that services remained affordable for low-income patients, they coupled the fee increase with a sliding scale. When these changes were first introduced, the clinic briefly experienced a decrease in patient numbers. However, it did not take long for the patient numbers to rebound. While COHS has always provided high quality oral health services, patient response to the fee increase has brought the value of their services to the forefront. Patients stayed. I m convinced that it s because they feel like they are getting quality services, reflected the executive director. Adjust patient mix. SNS recommended that COHS think more carefully about the number of self-pay patients and Medi-Cal patients they could afford and fill their scheduling accordingly. This strategy would enable a more predictable revenue flow as dictated by payer type for each patient. We re thinking more about [how we] schedule patients. It s creative scheduling for sustainable production, the executive director explained. This careful planning has placed COHS on a path toward greater financial stability. Recommendations Fully Implemented Implement a fee increase and sliding scale for self-pay patients Planning and scheduling for a sustainable patient payer mix Hire part-time accountant Move to an electronic billing system Maintain number of children and pregnant women in practice Implement process for documenting eligibility Adopt formal emergency policy Adopt no-show policy that incorporates a $25 deposit Implementation Ongoing Generate paper encounter forms Serve fewer sites to cut costs and focus on sites that demonstrate the greatest need for dental care Self-Reported Outcomes To Date Increased net revenue Increased productivity Decreased expenses Streamlined staff roles and responsibilities Increased clinic efficiency Reduced no-show rate Expected Increase access to services Streamlined communication flow between sites Increased efficiency and financial viability Hire part-time accountant. To keep track of costs, COHS replaced a former staff member with a part-time accountant. COHS faced significant problems with cash flow, and the accountant helped COHS take a deeper look at the clinic s finances and determine on how to move forward. We re owed $100,000 from one of our funders who has not paid us yet. We have to pay out all that money up front and [the cuts in grant funding] have set us back, the executive director explained. Transition to electronic billing. Upon recommendation by SNS, COHS transitioned from manual paper billing to electronic billing. With the new electronic claims billing in place, the clinic increased its revenue by 60 percent in one month, jumping from $18,000 to $30,000. Collection was a huge problem here and when we made the changes, we collected what we produced. Reflecting on the Project Practice management consulting was highly valuable to COHS. The clinic firmly believes that, without the practice management consulting provided by SNS, the clinic would have closed down. If we didn t follow the recommendations [from SNS] and make the conversion to essentially a Prepared by Harder+Company for the California HealthCare Foundation January

44 restorative, standard service type of dental practice, then I don t think there is any way [the clinic] could have survived even this long, explained a COHS dentist. COHS was highly satisfied with the services they received from SNS, but expressed that they would have liked more on-site support and hands-on guidance. Someone helping to actually implement recommendations and walking us through the process and helping us implement along the way [would have been helpful], says the executive director. Staff members were generally supportive of the changes, but implementation was a challenge because it tended to fall on just one person. Having regular in-person meetings with clinic staff and the consultants perhaps would have facilitated more shared involvement during the implementation phase. We re asking for help from SNS for strategic steps to take to preserve the services that we ve been providing to the community. - COHS Management COHS felt that SNS did not account for the full value of its mobile clinics in the community. Through community partners such as family resource centers and child care centers, COHS reaches a wide number of people who have minimal alternatives for oral care and prevention. Oral health is our expertise, but we ve grown into a much bigger asset in the community. Head Start and migrant education depends on us, early childhood education depends on us, and family resource centers depend on us, explained the executive director. COHS felt that the practice management consulting approach merely looked the business aspect, and did not fully account for the importance of mobile services in their community. They provide quality dental care and education in a community where mobility and accessibility are significant concerns. COHS did not want to reduce the mobility of their clinics in order to cut costs. We have a much better knowledge base of what it takes to run a community clinic in any economy. - COHS Management Working with SNS to improve clinic productivity and generate revenue allowed COHS to remain open and continue providing quality dental care for their patients. COHS management feels they now have a much better knowledge base of what it takes to run a community clinic in any economy. With the help of SNS, COHS emerged from a challenging year with significant revenue losses as a more viable dental practice with tools and knowledge to sustain future growth. COHS hopes that as a stronger, sustainable clinic, it will eventually re-incorporate its vision to provide dental outreach, education, and prevention. Prepared by Harder+Company for the California HealthCare Foundation January

45 County of Marin Dental Services County of Marin Dental Services (CMDS) is a public clinic funded by the Marin County Public Health Department. Their mission is to provide quality dental services to residents in Marin County. CMDS operates clinic sites in San Rafael, West Marin, and Novato. CMDS is dedicated to providing access to individuals of all ages who are eligible for public insurance or meet income requirements for self-pay. In order to receive services, patients must be residents of Marin County. CMDS clinics serve a large number of individuals whose primary language is not English. Many of their patients are immigrants and undocumented residents. At-A-Glance County clinic with three sites 8 full-time operatories (San Rafael), 3 portable dental set-ups (Novato and West Marin) 18,445 visits/year (FY 2008) More than 50% adult patients 46% Medi-Cal; 21% Healthy Families; 31% Self-pay; 2% County Medical Program Mostly low-income Latino and Asian immigrants Consultant: SNS Baseline Challenges and Goals At the start of the demonstration, CMDS served mostly adult patients who were undocumented or homeless residents of the county. With cuts to Medi-Cal adult dental benefits and the county s fiscal troubles, CMDS became concerned about the dental clinic s financial viability moving forward, and was considering laying off one of their dentists. In the past, CMDS relied on the county for about onefifth of their funding. To add to their financial woes, CMDS also faced the threat of increased competition from the local FQHC, Marin Community Clinics (MCC), which opened new a dental clinic nearby. As an increasing number of people lost their jobs and health benefits, CMDS struggled to reconcile their need [for] financial viability with their mission of providing quality dental services to all. With the economy being bad, we are more in demand now We are reluctant to turn clients away. Recommendations and Outcomes SNS s recommendations provided the clinic with greater structure, and as a result reduced the level of stress in day-to-day operations. It was a change of mindset in expended energy Where one could be productive without killing themselves. However, CMDS voiced that while their work with SNS has helped streamline operations, it had little impact on their financial viability and productivity. They were already in good standing before the demonstration project, but wanted to see if there was further insight to be gained from the consultants. Prior to the demonstration project, CMDS reduce the threat from MCC by establishing a partnership with them as a subcontractor. CMDS s partnership with MCC has strengthened their finances by providing a steady stream of patient referrals and revenue. Modify scheduling. SNS recommended implementing a no-show policy that would allow only two consecutive no-shows before a patient is dismissed from the practice. However, CMDS was highly concerned about turning away patients during hard economic times. Instead, the clinic implemented Prepared by Harder+Company for the California HealthCare Foundation January

46 a revised version whereby four consecutive no-shows are allowed before any punitive action. After four consecutive no-shows, the patient would only be scheduled for stand-by appointments. The Recommendations Fully Implemented Implement no-show policy Avoid scheduling appointments too far in advance Implement a triage process and eliminate walk-ins Hired dental consultant to oversee quality of care Increase the number of children served Develop formal collaboration with external agencies Did Not Implement Consider accepting private insurance Institute an incentive plan for dentists Increase fees and implement a sliding scale (under review) Require patient proof of income Create school-based oral health programs revised no-show policy has been successfully implemented with no complaints from patients thus far. To further reduce no-shows and shorten waiting lists for appointments, CMDS further advised to avoid scheduling appointments too far in advance. Clinic staff members were initially worried about a negative response from patients. However, staff members have been consistent in scheduling appointments no more than six weeks in advance, and it has contributed to a reduction of clinic stress levels. Adopt triage process for walk-in patients. CMDS feels the most successful change is the triage process they have instituted for walk-in patients. With the help of SNS, the clinic developed a triage form to assess a patient s level of pain and determine if the situation is an emergency. By sorting out which patients required emergent care and which patients could be scheduled for a later time, CMDS was able to significantly reduce stress levels for front office staff and wait time for patients. Create quality of care oversight. Since many of the dentists at CMDS are hired directly from dental school, CMDS hired a dental consultant to provide direct oversight in quality of care. The consultant s Self-Reported Outcomes primary responsibilities include chart audits, oversight of treatments, and recommending strategies for quality improvement. The consultant has an active role in reviewing and updating dental protocols with the dental director. Adjust patient mix. With the elimination of Medi-Cal adult coverage, CMDS adopted a number of changes to enable the clinic to serve more children and draw in more revenue. The clinic now has one dental suite specifically designed for and dedicated to children, which has been highly successful in bringing in more pediatric patients. Their success in this arena was catalyzed by partnerships with MCC and the Childhood Health and Disability Prevention Program to generate more pediatric referrals. Reflecting on the Project To Date Reduced losses despite serving more self-pay patients Increased clinic efficiency Reduced stress for clinic staff Expected Development of quality assurance procedures and higher quality of care When asked to reflect on their experience with practice management consulting, CMDS felt that it was a tremendous help to have someone come in and see where we can make improvements. In particular, [SNS s recommendations] provided more structure and allowed us to look at areas for Prepared by Harder+Company for the California HealthCare Foundation January

47 improvement. We were so rushed and not paying attention to how we re doing our job. [SNS] helped us fine tune the process. The practice management consulting experience has helped CMDS develop a culture of reflection and continual improvement. For example, regular staff meetings are now held regularly to review and refine clinic operations. [SNS] has transformed us in that we re actively looking for [areas of improvement]. We look for problems and think about how we can do our work better. - CMDS Dental Director Overall, CMDS was very satisfied with SNS. In particular, they appreciated that SNS spoke the same language with like experiences and that the relationship was collaborative in nature. Although they would not be able to fund consulting services on their own, CMDS felt that it represented money well-spent. Due to requirements and policies set at the county level, CMDS did not have full freedom to implement all of the changes SNS suggested. For example, one recommendation was to implement an incentive program for dentists, something in which CMDS expressed interest. However, as a county clinic, CMDS s employees belong to a union which disallows a separate incentive program for dentists. Additionally, changes to the fee schedule require approval from the Board of Supervisors and from county residents through a public hearing. Recommendations to increase fees and implement a sliding scale are currently under review. CMDS struggled with implementing certain suggestions because of their mission of providing access to all Marin County residents. For example, they felt that requiring patients to bring proof of income would only create more barriers for the patients they served many of whom are undocumented or homeless. CMDS felt policies that create barriers to access are in conflict with their purpose as a public clinic and create misalignment with the other county clinics. CMDS s experience speaks to the struggles and tradeoffs that many safety net clinics face in these challenging economic times. With the economy being bad, we are more in demand now. [People are] losing jobs and losing benefits. We are reluctant to turn clients away. - CMDS Dental Director Prepared by Harder+Company for the California HealthCare Foundation January

48 Del Norte Clinics For over 40 years, Del Norte Clinics (Del Norte) in Sutter County is a federally qualified community health center that has provided affordable medical care to underserved populations, regardless of their insurance status or ability to pay. Del Norte Clinics originated as a medical care project for migrant farm workers. Today, the organization operates 13 medical facilities, six dental clinics, and a mobile health center. They offer comprehensive primary medical and dental care to ethnically diverse communities in five rural northern California counties. The Oroville Family Health Center, one of Del Norte s longest running clinic sites and the focus of this project, was started in The Oroville clinic is a state-ofthe-art dental facility that takes pride in serving a low-income community that often has no other options for dental care. Del Norte s once-booming lumber and construction industry has dried up and as a result, unemployment rates are high. The clinic regrets that many of the town s residents struggle with substance use issues. Baseline Challenges and Goals Del Norte faces immense challenges scheduling regular and follow-up appointments for general dentistry. It s a challenge to get people to come in, even though our fees are lower than any surrounding clinics, explained the clinic manager. Patients generally come to the clinic in the case of an emergency, and they seldom to follow through to treatment completion. Because Del Norte is the only local facility offering walk-in urgent care dental visits, the clinic can become overwhelmed by walk-in patients. The clinic has a high no-show rate, with sometimes only one in 10 scheduled patients coming in for their appointments. Nevertheless, Del Norte staff noted, The patients have remained loyal to us throughout the year, even as their circumstances have changed. Del Norte hoped that their engagement with Pride Institute would provide them with a fresh pair of eyes to see what the clinic was doing well and identify areas for improvement. The economic crisis forced the clinic to prioritize day-to-day survival over improvements for long-term stability. In the face of massive funding cuts, the Del Norte dental clinic has maintained its commitment to serving patients who have alternatives for dental care despite a 60 percent cut in their funding for subsidized care. Their greatest challenge is to cut costs, yet still maintain services for uninsured patients. Discontinuation of the Project At-A-Glance FQHC with 5 dental clinics 12 operatories >5,000 visits/year 64% adult patients 71% Medi-Cal Low-income patients, many with substance abuse issues Consultant: Pride Institute Although clinic management felt that Pride came up with a number of promising recommendations, staffing and economic challenges led Del Norte to discontinue their involvement in the practice management consulting. As described by staff, by far the biggest reason the project was put on hold was the unanticipated departure of the dental director. Any new project has to have a leader, and Del Norte s management asserted. While interacting with Pride more frequently could have helped, Del Norte believed that no substantial progress could be made without a dental director. Prepared by Harder+Company for the California HealthCare Foundation January

49 Recommendations and Outcomes Despite Del Norte s discontinuation of the project, the clinic still implemented a number of recommendations. Change front-line operations. Del Norte had three per-diem employees for the front office rather than full-time staff members. Pride suggested transitioning Del Norte s per diem staff to full-time status as a way to increase both job satisfaction and the cohesiveness of the front desk team. Though initially resistant to the idea, Del Norte implemented this recommendation and hired two of their per-diem staff as fulltime staff with benefits. The clinic has also taken an interest in providing customer service training for the two front office employees. Adjust patient mix. At Pride s suggestion, Del Norte has increased their outreach to pediatric and self-pay patients. Del Norte has participated in local health fairs to do pediatric screenings, and assisted with county wellness programs to perform check-ups with children. Children have always been a substantial portion of their patient base, but they have made a concerted effort to recruit more. As a way of recruiting more self-pay patients, Del Norte has been reaching out to seniors who have lost their dental benefits. Community dental clinics may be appealing to seniors since service fees are much lower than that of other local clinics. Reflecting on the Project Del Norte appreciated the opportunity to learn from experts in practice management, but felt that many of the recommendations were in conflict with Del Norte s values and federal mandates as an FQHC. For example, Del Norte did not feel that a strict enforcement of the no-show policy was Recommendations Fully Implemented Transition per-diem staff to full-time staff Increase outreach to pediatric and private sector patients Upgrade dental equipment Improve follow-up with patients for completion of treatment plans Implementation Ongoing Create new fee schedules for self-pay patients Create new job descriptions and increase training for front desk staff Upgrade to Dentrix software and move toward digital records Create more formal orientation for dental students Offer sedation during appointments Redesign forms and procedures to increase patient education and accountability Create continuing care department that provides patient education Collect detailed clinic statistics and track on a monthly basis Create triage and estimate forms for walk-in patients Not implemented Reconsider incentive compensation program for dentists Stagger dentist shifts Consider hiring a full time hygienist and a full time assistant Upgrade walk-in and cancellation policies to include penalties Create new job titles and positions for staff Hire a greeter for the lobby Allocate staff person to work as patient advocate Self-Reported Outcomes To Date Hired per-diem staff as full-time Purchased panoramic x-ray machine Reached out to pediatric patients through health fairs and county wellness programs Served more private pay patients Expected Improved front desk management and customer service Enhanced job satisfaction among front desk staff Improved rates of treatment plan completion Prepared by Harder+Company for the California HealthCare Foundation January

50 practical. For their Oroville clinic, they are the only clinic in the area accepting walk-in patients and many of their patients are quite poor with few alternatives for dental care. For the same reasons, Del Norte did not want to stagger dentist shifts to create tighter schedules. The clinic takes pride in their ability to respond immediately to emergency walk-in patients when they are in need. Staff would have been more receptive if they had approached us in terms of helping us versus fixing us. - Del Norte Clinic Manager While many of the consultant s suggestions were helpful, Del Norte did not feel they were practical for their clinic and many were too costly to implement in the near future. Suggestions included taking more time to educate patients, hiring more hygienists and dental assistants, upgrading to a new dental computer system, and moving to digital patient records. If the opportunity to receive technical assistance arises in the future, Del Norte suggested that more could be done to improve buy-in within the clinic. More specifically, Del Norte felt that dentists should be included in the decision-making process and the consultants could have approached the engagement differently: Dentists at Del Norte rely on the incentive program for supplemental income, and they are wary of any changes that might reduce the number of patients they see. Dentists might be less resistant to the proposed changes if they were included in the decision-making process. Front-line staff felt the project would have been more successful if the consultants approached them as collaborative partners. They felt that the engagement focused on the clinic s weaknesses rather than its strengths, and the recommendations did not align with their values as a safety net clinic. The clinic manager lamented that the process may not have met its potential as a result. Del Norte staff highlighted the importance of tailoring the consulting approach to each dental practice. Each clinic is unique and comprised of staff members who take pride in providing a much-needed service to a vulnerable population. Del Norte feels that the clinic could still benefit from their engagement with Pride Institute if the new dental director fully commits to the project, sets up a timeline for implementation, and secures staff commitment from both the front and back offices. I think there s potential if [the project] had happened at the right time. - Del Norte CFO Prepared by Harder+Company for the California HealthCare Foundation January

51 Inland Behavioral and Health Services Established in 1978, Inland Behavioral and Health Services (IBHS) in San Berdardino County is a federally qualified community health center that offers a wide range of services including primary care, obstetrics & gynocology, substance abuse treatment, mental health, and oral health. IBHS started its dental program in 2003, and expanded in 2008 to include six dental suites and one operatory at a satellite clinic. IBHS is located in a low-income housing community. The clinic serves a largely low-income, uninsured population with an estimated 70 percent of its patient population living at or below the poverty line. The patients represent an even mix of Latino, African American, and Caucasian residents. At-A-Glance FQHC with 2 clinic sites 5 operatories 4,364 visits/year (FY2008) ~70% adult patients 51% Medi-Cal; 47% Self-pay Mostly low-income and uninsured patients, including the homeless population Consultant: SNS Baseline Challenges and Goals Although IBHS started out serving mostly children at its inception, the clinic has since evolved into a practice that primarily serves adults. Adults comprise about 70 percent of their patient population, and IBHS was hit hard by the elimination of Medi-Cal adult dental coverage. We have virtually no pediatric population as far as dental goes, explained their health administrator. With SNS s help, IBHS sought to put a spotlight on kids and pregnant women again. IBHS s goal was to improve operational efficiency and hence financial solvency. Clinic management saw that there was room for improvement and looked to practice management consulting to put them on firmer financial footing. As their health administrator explained, We knew that we had some challenges but we didn t have enough history and experience with a high volume practice to pinpoint these things and fix them. Recommendations and Outcomes From the start, IBHS staff and leadership showed significant motivation, buy-in, and openness to change. For IBHS, practice management consulting promised much-needed guidance on how to maintain clinic sustainability in the long term. IBHS management explained, We were ready...there was an internal realization that something s got to change, but what do we need to change? Recommendations Fully Implemented Implement triage process for walk-ins Implement no-show policy Improve scheduling: scheduling by operatory and staggered scheduling Improve staffing Educate staff on Phase I Treatment Use designated access scheduling Avoid scheduling appointments too far in advance Increase the number of children and pregnant women served Develop collaboration with internal departments and programs Increase fees and sliding fee schedule Require patient proof of income IBHS found their consulting experience to be comprehensive and invaluable. They worked on increasing fees, modifying scheduling, improving Did Not Implement Determine productivity goals Implement incentive plan for providers Prepared by Harder+Company for the California HealthCare Foundation January

52 staffing, and educating staff on Phase I treatment. The improvements are making us more money, we have a better scheduling practice, we ve been touched in many different ways, and our practice has dramatically improved, IBHS management commented. Increase clinic fees. SNS recommended that IBHS update their fee schedule, which was very low compared to what was usual for the area. In the past, IBHS struggled with fee increases because they would see a drop-off in scheduling. To counter this issue, the new fee schedule was implemented with a patient education strategy. They also took extra steps in ensuring that patients understood the new fee schedule and the value of the dental service that they were receiving. For example, staff would explain to a root canal patient that the actual value of the service is $1,500 but patient only pays $600 with the clinic s lower prices and sliding scale fee schedule. Patient education was key to keeping patients satisfied despite the increased fees. We informed the patient of the value of the service and that made a huge difference, explained IBHS management. The fee schedule has contributed to stronger financial viability for IBHS, and they feel strongly positioned for the coming year. Self-Reported Outcomes To Date Served more pediatric patients Improved clinic efficiency Improved patient flow Increased revenue Increased productivity Reduced no-show rate Expected Improve financial viability moving forward Improve quality of care with an eye toward Phase I treatment Modify scheduling. IBHS implemented policies and procedures to help them manage patient flow more easily. Two of the more successful changes cited by IBHS were the implementation of a triage process and no-show policy. Prior to the project, all walkin patients were classified as emergencies regardless of severity or urgency. This created bottlenecks and was often disruptive to the clinic s schedule and flow of the day. Upon SNS s recommendation, IBHS implemented triage procedures for emergencies and walk-ins which allowed for better management of the clinic s schedule as well as appropriate treatment of emergencies. Improve staffing. SNS identified ways in which IBHS could improve its staffing to maximize efficiency and generate more revenue. IBHS improved staff scheduling patterns by staggering shifts and dedicating a staff person to serve at the front desk. These steps helped to ensure sufficient coverage during peak hours and smoother patient flow. IBHS also replaced their hygienist with a dentist. This was advantageous in bringing in more revenue since the dentist has a much wider scope of practice. Educate staff on Phase I treatment. IBHS appreciated SNS s help in thinking about the quality of care provided at the clinic. Specifically, SNS encouraged them to look at Phase I treatment, something with which IBHS had little familiarity. In response, IBHS altered their practice management system to track which patients have completed Phase I treatment and returned to basic oral health. The outcome is [that] we pay attention to the overall care of our patients, and we don t just provide episodic care, explained management. Reflecting on the Project When asked to reflect on their experience with practice management consulting, IBHS highlighted SNS s credibility, expert diagnosis, and collaborative engagement style as key factors in their success. Clinic staff at all levels saw SNS consultants as experts who understood IBHS s mission and unique Prepared by Harder+Company for the California HealthCare Foundation January

53 challenges as a safety net dental practice. IBHS valued SNS s experience as dental providers who themselves had worked in high-need communities. [SNS] understood not only what was going to make the practice viable, but also the impact on provider. [They] came knowing how to do it better, from a management, administrative perspective, and also from the perspective of providers, explained their health administrator. IBHS was very satisfied with the consulting experience and particularly valued SNS s collaborative approach. Management appreciated that [SNS] worked with us to develop recommendations and strategies. They didn t tell us what to do. It was a collaborative effort and they spoke with authority, knowledge, and experience. IBHS also noted the value of the resources that SNS provided through its webinars, such as the session on risk management and schedule strategies. They found the webinars to be a quick and easy way to learn new and relevant information. [SNS] brought to light the issues that we could not see. We had a feeling, we knew something wasn t quite right, but they were able to collect the data and synthesize it. - IBHS CEO IBHS s needs were a good fit with the consulting model and the clinic was positioned to really take advantage of the expertise available to them. IBHS was ready for real change and SNS helped them achieve it: The practice needed help with everything primarily as a result of cuts in Medi-Cal, they are close to collapsing so they need a complete system overhaul. And SNS, they can take the whole system apart and make recommendations. Prepared by Harder+Company for the California HealthCare Foundation January

54 La Clínica de la Raza La Clínica de la Raza (La Clínica) began in 1971 as a small storefront clinic to serve the residents of East Oakland. Since then, La Clínica has grown to be one of the largest community-based clinics in the state of California, with 25 sites throughout Alameda, Contra Costa and Solano counties. Today, La Clínica provides comprehensive medical and dental care, along with women s health, nutrition and prevention services. With a mission of providing as much preventive and basic care for as many patients as possible, La Clínica provides low-cost dental services to underserved communities at six Bay Area sites and operates a mobile clinic in Contra Costa County. At-A-Glance FQHC with 6 sites and 1 mobile clinic 10 operatories >5,000 patients/year 50% pediatric patients 49% Medi-Cal; 32% self pay Mostly low-income, uninsured Latino patients Consultant: Pride Institute Baseline Challenges and Goals La Clínica is highly dedicated to providing affordable dental care to low-income families and individuals, and has deep connections with the community. The clinic makes it a priority to hire staff members from the community, and prides itself in having high staff retention. La Clínica feels that its greatest challenges are in the high levels of stress in day-to-day operations as well as uncertainties with regard to clinic leadership and decision-making structure. La Clínica is often overwhelmed by the high demand for their services and what feels like a perpetual shortage of staff. The dental clinic did not have a clinic manager for an extended time period, which contributed to greater stress and chaos in the practice. With the added challenge of the loss of adult Medi-Cal dental benefits, the clinic was starting to feel pressure financially and operationally. La Clínica management hoped that their work with the Pride Institute would improve their clinic s organization and efficiency, and therefore improve patient care. Recommendations and Outcomes Overall, La Clínica management felt that Pride Institute put forward an accurate assessment of the clinic s strengths and weaknesses, especially considering that La Clínica provided the consultants with only limited data. Pride Institute offered a number of new ideas on how to improve operations, as well as confirmation of some issues that staff had suspected. Clinic management particularly appreciated their suggestions around improving teamwork and accountability among staff. Upon review of the recommendations, clinic management decided to the following priorities: new job descriptions for staff, an incentive program for dentists, and better use of dental students who rotate through the clinic. However, without the leadership and authority of a clinic manager, the clinic had trouble taking ownership of the project and implementing changes in policies and procedures. While the administration for the greater health care agency was generally supportive of the project, many of the recommendations were not able to move forward and actions got stuck at the administration level. Challenges in gaining staff buy-in also posed significant roadblocks to the success of the project. Prepared by Harder+Company for the California HealthCare Foundation January

55 Recommendations Fully Implemented Increase internal channels of communication Add goal-setting to the morning huddle agenda Improve student orientation and feedback models Revise of dental clinic mission statement Incorporate more administrative time into dentist schedules Implementation Ongoing Revise of clinic fees Institute compensation incentive program Revise job descriptions and titles Institute cross-training between dental assistants Provide more staff training on cancellation and no-show policies Provide professional development opportunities Incorporate more patient education Develop a marketing plan for retaining adult patients who lost Medi-Cal dental benefits Upgrade to digital x-rays and record system (on hold due to economy) Did Not Implement Create an Ideal Day template for dentists Restructure to allow two chairs per dentist Incorporate plaque control instruction into regular appointments Implement highlighting system to mark treatment plan progress Update emergency care screening system Revise charting system Self-Reported Outcomes To Date Improved internal communication Clarified roles for the leads and manager, as well as areas of responsibility and authority Expected Increase accountability Improve front desk operations Increase productivity Improve staff morale Improve quality of care Improve financial viability Many long-term staff members had witnessed failed attempts to institute changes in the clinic, and were therefore skeptical about the possibility of change. Establish policies and procedures. The consultant suggested felt that enhancing teamwork, motivation, and accountability would lead to greater efficiency within the clinic. La Clínica staff agreed that new job titles and descriptions would clarify roles and reporting structures, therefore leading to more accountability for each team member. Clinic management explained that new job descriptions are in the works, and they are gaining union approval for the new job titles. La Clínica also instituted more meetings and formal structures of communication among staff. The consultant suggested an agenda and structure for morning huddle meetings, and the clinic to meet more frequently and for longer periods of time. However, since administrative time takes away from time for patient appointments, it was unlikely that they could allocate additional time for meetings. Conduct staff training. La Clínica is committed to hiring staff from the local community, many of whom have only a high school education. Pride Institute emphasized the importance of ensuring that clinic staff members have sufficient professional development and training. In order to maintain smoother patient flow, front desk staff needed additional training in setting appointments, billing, and managing walk-in emergency patients. La Clínica agreed and is working on expanding formal training for clinic staff. They are looking to appoint select staff members to conduct trainings. Additionally, they have revamped the dental student orientation in hopes of making greater use of resident dental students as a resource. Prepared by Harder+Company for the California HealthCare Foundation January

56 Increase clinic fees. One significant change that will be effective at the start of the fiscal year will be a long overdue revision of their fee schedule. La Clínica will keep fees for basic services the same while increasing fees on more complicated procedures to reflect local rates. Fees have not been changed in two or three years, and this modification should contribute to La Clínica s financial viability going forward. Reflecting on the Project Commenting on the practice management consulting experience, La Clínica staff valued Pride Institute s level of organization and follow-up during a chaotic time for the clinic. Staff appreciated opportunities for face-to-face contact with the consultants and management noted that their attendance at La Clínica s staff meeting was especially helpful in explaining proposed changes to staff. The consultants were energetic about helping La Clínica and sought feedback from each level of staff. They made sure to touch base with each person. They know everyone on the staff by name, reported one of the back office leads. I wanted more support and an ally [in the process]. - La Clínica Associate Dental Director Clinic management also shared that they would have liked to work more closely with Pride Institute during the implementation phase. The associate dental director expressed that La Clínica s challenge is that the administration often does not see new ideas and changes through to the end, and she needed help in managing change within the organization: I would have liked more hand holding during the process of making changes. Given that my challenge is to implement [the changes], I wanted more support and an ally [in the process]. Notably, clinic staff reported experiencing less disparity between Pride Institute s private practice background and La Clínica s community clinic roots than they had expected. However, they did feel note that there were some suggestions that seemed less appropriate for them. For example, La Clínica felt that shifting the clinic s emergency screening system to a phone triage system would not work, as most clients simply show up to the clinic without calling in advance. Additionally, they did not agree with their suggestions around increasing the number of patients served and felt that instead, the clinic should focus on doing the same amount of work in a wiser way. I m glad we got the chance to be evaluated and work with Pride. It would be a great opportunity for other clinics in the future. - La Clínica Associate Dental Director Reflecting on their involvement in the demonstration project, La Clínica management felt that it was useful to gain an independent view of how the clinic could improve. However, they were unable to take full advantage of the project due to internal issues. Due to issues with management and communication, the associate dental director (who was later charged with implementation) was not fully informed of the purpose of the consulting work. The lack of a clinic manager also created challenges to implementing changes in policies and procedures. With a clinic manager now in place, they hope that some of the recommendations will be able to move forward and they could go from our best to getting better. Prepared by Harder+Company for the California HealthCare Foundation January

57 Mission Community Hospital Dental Clinic The Mission Community Hospital Dental Clinic (Mission) in Los Angeles county was established in 2005 through a partnership between Mission Community Hospital and a private foundation in California. It was founded for the purpose of increasing access to dental care for low-income adults in San Fernando. Surrounded by more affluent areas of the San Fernando Valley, the city of San Fernando is home to individuals who experience a variety of socioeconomic, language and cultural barriers. Mission serves mainly Latino patients, many of whom only speak Spanish. As an organization, Mission seeks to fill gaps in their community s oral health needs through the patients they target and the services they provide. They primarily serve uninsured adults, and are often the destination for more complicated dental procedures. Other community clinics will often refer their patients to Mission for procedures such as posterior crowns, root canals, and prosthetics. Baseline Challenges and Goals Mission s purpose is to provide dental care to uninsured adults, a population that Mission Community Hospital has identified as highly underserved. To meet this goal, Mission has relied heavily on grant funding from its private foundation partner, which provided approximately 57 percent of the clinic s revenue. With the recent economic downturn, the clinic s grant funding has evaporated and they have since struggled to adjust to a much tighter budget. Despite primarily serving adults, Mission was not hit very hard by the elimination of Medi-Cal adult dental coverage which brought a relatively small portion of its revenue the previous year. Although Mission is a site-based clinic, the clinic relies on portable equipment since the operatories are not set up with the plumbing that dental equipment requires. Despite the logistical complications of portable equipment, the clinic staff and dentists have provided quality comprehensive dental care for a community in need. Mission s goals for practice management consulting were to formalize the clinic s internal policies and procedures as a way to streamline clinic operations and hopefully build stronger financial viability. With its plans to expand the dental clinic, Mission hopes that efficiencies gained through this process will carry over to the expanded clinic. Recommendations and Outcomes At-A-Glance Hospital-affiliated nonprofit clinic 3 operatories <2,000 visits/year (FY 2008) 82% adult patients 80% self-pay; 20% insured 57% revenue is grant-funded Mostly low-income, uninsured Latino patients Consultant: SNS Mission executed a number of SNS s recommendations regarding scheduling and increasing clinic fees which resulted in more formalized and efficient operations. Mission felt that SNS s most valuable recommendations were related to the clinic s policies and procedures. New protocols related to scheduling, patient eligibility, and fees has added structure and contributed to a more smoothly-run clinic. Having formal policies and procedures, as well as being more conscious of the actual cost of treatment, has helped the clinic stay on top of finances. Prepared by Harder+Company for the California HealthCare Foundation January

58 Mission was also very pleased that SNS helped them to negotiate a good deal with an equipment supplier in Colorado. As a result, the clinic was able to afford a new Pro-Cart, a self-contained portable dental operatory, which they believe will greatly contribute to the dentist s productivity. The clinic noted that successful implementation was facilitated by the strong support of clinic staff. We believe in making this a workplace where people can grow and support their families. Our staff appreciates that and is on board for keeping the clinic sustainable. While the hospital administration was not deeply involved in the process, they have trusted the dental clinic management to take the reins and implement the changes necessary. Increase clinic fees. SNS came up with a sliding fee schedule for Mission that was comparable to that of other clinics in the San Fernando area. Mission felt that instituting a sliding fee schedule was a welcome change for the clinic, and they would never have been able to implement it so quickly without the help of SNS. However, the lowest fee level has turned out to be lower than what the clinic could sustain. In the end, the clinic worked with SNS to revise the sliding scale. Because surrounding FQHCs are able to offer lower fees, Mission faces the ongoing challenge of being competitive yet sustainable. Self-Reported Outcomes To Date Acquired new equipment Trained front desk staff on documenting eligibility and explaining the sliding fee scale to patients Increased incidence of upfront payment Instituted scheduling such that time slots are set aside for emergency patients Eliminated double-booking Increased productivity Reduced no-show rate Expected Improved patient understanding of the value of services provided Continue streamlining of front desk operations Enhance efficiency through improved clinical protocols Recommendations Fully Implemented Verify dental Medi-Cal eligibility electronically and use electronic claim submission Institute designated access scheduling Avoid double booking Implement sliding fee scale and revised fee schedule Develop policies and procedures manual with policies for managing self-pay patients, collecting co-pays from patients, and handling no-shows Upgrade dental equipment Implementation Ongoing Educate patients about the value of services Revisit front desk job description Develop new scheduling template Define and document system for billing Define scope of clinical services Develop financial and productivity goals Did Not Implement Increase the number of children and pregnant women with dental Medi-Cal in the practice Modify Scheduling. SNS identified Mission s policies around scheduling as a key area for improvement. The clinic has also begun instituting designated access scheduling for emergency, pediatric and other patients. In addition, both front desk staff and the clinic s dentist have been more careful about sticking to scheduling and treatment plans for each patient so as to maintain the day s schedule. Clinic staff noted that the nature of the population they serve has posed challenges to enforcing their no-show policy. The clinic administrator explained, The reason this clinic exists is to increase access for adult dentistry which is one of the major health issues in the community. We can t lose that foundation. Some patients may not have Prepared by Harder+Company for the California HealthCare Foundation January

59 control over their work schedules, and Mission values their ability to accommodate this high-need population and help them obtain the services they need. Define scope of services. To enable greater access for all patients, SNS encouraged Mission to think more carefully about the services provided at the clinic. In the past, Mission would occasionally perform cosmetic procedures for patients and the cost of these services inhibited the overall sustainability of the clinic. Mission has since backed away from offering cosmetic procedures, and patients may now only receive cosmetic procedures if they pay for the full cost of service. Require proof of income. SNS advised Mission to require patients to provide proof of income in advance of their visit. This would add more structure and consistency to their eligibility and payment processes by requiring clients to provide proof of income and submit their payment at the time of service. However, many patients were not able to follow through on this request and Mission abandoned this policy. Reflecting on the Project Based on their previous experience with consultants, Mission staff entered the consulting process with skepticism. However, they were pleasantly surprised and noted that SNS was quite down to earth, and very realistic about what could and could not be done. Staff felt that SNS looked beyond the bottom line and had more of a feeling for community dentistry. I like the fact that they are able to point out weaknesses and create a plan to try to overcome any problems. - Mission Dentist Mission felt that SNS was most helpful in implementing the sliding fee scale and connecting Mission to new dental equipment. However, there were some challenges to adhering to the new sliding scale with their current patient population. According to the clinic administrator, Safety Net Solutions gave us some data and put together a sliding scale for us, but very honestly we had to go back to them and say, Your 30 percent is lower than what we re charging now, and we can t afford to go to that level. Mission staff felt at times that the consultants did not fully understand their clinic. Their suggestion about increasing the pediatric patient load did not fit Mission s purpose and reality. Mission is surrounded by FQHCs who already serve the majority of pediatric patients, and they do not feel that they can realistically increase their pediatric population. One member of the larger hospital administration felt that although his interaction with SNS was limited, he had hoped SNS would provide more detailed financial projections based on the number of patients served by the clinic. We can t make the bulk of our practice children the need here is to serve adults who are uninsured. - Mission Clinic Administrator While practice management consulting provided a useful outside perspective on clinic operations, Mission feels that they would have preferred added funding in place of consulting services. However, when they are in a place to expand the clinic in the future, they feel the expertise of practice management consulting would be very helpful. Prepared by Harder+Company for the California HealthCare Foundation January

60 Native American Health Center The Native American Health Center (NAHC) was established in 1972 to meet the health care needs of Native Americans in San Francisco. Native Americans had little access to mainstream health care systems at that time, which motivated community leaders to seek funding from the federal Indian Health Service to create the Native American Health Center. Today, NAHC is an FQHC that provides a range of services comprising primary medical care, comprehensive dental care, HIV/AIDS prevention and treatment, youth services, and general nutrition and fitness. NAHC offers dental services including patient education, prevention and general dentistry for adults and children. Over the years, NAHC has expanded to a site in Oakland. While NAHC s primary focus is on Native Americans, the clinic aims to serve any and all members of underserved communities in the Bay Area. In San Francisco, the clinic serves mostly low-income and no-income adults, many of whom are homeless, disabled, and have mental health or substance use issues. Baseline Challenges and Goals NAHC s San Francisco clinic was chosen to participate in the demonstration project through its involvement with the California Pipeline Program. Non-standardized clinic operations, coupled with the economic crisis and elimination of Medi-Cal adult dental benefits, resulted in a focus on putting out fires. As a result, it became difficult for clinic management to step back and look at the big picture. The clinic had been trying to handle issues internally, but encountered significant roadblocks with internal processes at the administration level. NAHC s overarching goal in pursuing practice management consulting was to improve the financial stability of the clinic by implementing best practices and improving efficiency. NAHC management expressed particular interest in benchmarking their internal processes and procedures against those of other clinics to see where they stood. The clinic had an added goal of expanding its thriving pediatric program by starting portable clinics at Head Start sites throughout San Francisco. Recommendations and Outcomes At-A-Glance FQHC with clinics in San Francisco and Oakland 6 operatories >7,000 visits/year (FY 2008) 79% adult patients 48% Medi-Cal; 20% self-pay Mostly low-income Latino and Native American patients Consultant: SNS NAHC has implemented a number of SNS s recommendations with positive results. During the implementation phase, a key challenge for NAHC was the buy-in and commitment of clinic staff and administrators. While at first some staff members were wary of the changes, most were willing to take the steps necessary to improve clinic operations with the hope that changes would relieve job stress and improve patient care. Nevertheless, full clinic ownership and buy-in of the recommendations is a process that takes time. Prepared by Harder+Company for the California HealthCare Foundation January

61 Recommendations Fully Implemented Increase overall fees Institute new sliding fee scale Train front desk staff on eligibility and billing requirements Review and create new job descriptions for front desk staff Continue to develop portable oral health program Increase the number of children and pregnant women Move scheduling to Dentrix software Implementation Ongoing Standardize clinical procedures Improve scheduling through provider education and dedicated access scheduling Engage billing department to create an improved system for billing Engage Third Party Manager to understand denied Medi-Cal claims The administration was generally supportive of the project and allowed the dental clinic a fair amount of autonomy in implementation. However, it was difficult for NAHC to engage key members in the larger FQHC, whose cooperation was needed in decision-making and in generating data for monitoring progress. NAHC has found that working with outside facilitators and prioritizing face-to-face meetings with executive leadership has helped to mitigate challenges in moving forward with the recommendations. Increase clinic fees. Following SNS s recommendation, NAHC increased their overall fees while also deepening the sliding scale discount for the clinic s most disadvantaged self-pay patients. These changes, along with improvements in the clinic s efficiency, have led NAHC to successfully triple its monthly cash and insurance collections. While the clinic used to collect approximately $5,000 per month, they now collect an average of $18,000 per month with one month bringing in over $30,000. As a result, NAHC has been able to maintain revenue stability despite the cuts to adult dental benefits. Additionally, staff agreed that the sliding fee schedule has contributed to greater access to services. Streamline front line operations and train staff. NAHC felt that changes to the front line operations have made the most significant and long-lasting impact. Front desk improvements include streamlining the process for determining eligibility and training staff. Staff trainings would include information on how to triage patient concerns and explain the value of services to self-pay patients. In many cases, NAHC is subsidizing about 60 percent of the cost for self-pay patients and it is important that they understand that. These changes contributed to NAHC s success in tripling its revenue within months of implementation. Activate portable clinics. Clinic management noted that the consulting process has been very synergistic with the rollout of NAHC s portable clinics at Head Start sites. The portable clinics have furthered NAHC s ability to reach those most in need of oral health services. NAHC is able to provide access to services in two zip codes that previously lacked any pediatric Medi-Cal providers. NAHC now operates eleven portable clinic sites, with more in the works. As of March Self-Reported Outcomes To Date Tripled monthly cash and insurance collections Increased pediatric pool and added time for pediatric dentist Served over 300 low-income children at eleven new portable clinics at Head Start sites Increased productivity Reduced losses Expected Meet dental quality indicators Increase access to services for emergency patients Improved efficiency 2010, the new clinics have reached 310 low-income children ages 0-14, nearly all of whom are from underserved communities. Prepared by Harder+Company for the California HealthCare Foundation January

62 Reflecting on the Project Looking back on the experience with practice management consulting, NAHC found that they appreciated SNS s expertise in working with community health centers, especially portable clinics, and their support in confronting the cuts to Medi-Cal adult dental benefits. We were in panic mode in the executive management team [about Medi-Cal]. SNS was able to come in as an outsider to look at the numbers [and] they had positive things to say about what we were already doing, explained the dental director. NAHC appreciated SNS s ability to pull customized information with a fast turnaround, and felt that the visual presentation of findings and timelines made recommendations easy for executive management to digest. They especially liked the inclusion of Health Resources and Services Administration (HRSA) standards indicating benchmarks of what a typical clinic achieves. It gave them a sense of what [they] do that seems within the norm, and what seems like an outlier. We ve been empowered to go into communities of need There is value [in practice management consulting] not just in terms of the dollar for dollar return, but in terms of public health. - NAHC San Francisco Dental Director SNS was especially helpful in identifying and prioritizing low-hanging fruit action items that could be undertaken right away with immediate results. For example, streamlining internal policies and procedures was relatively easy, while cross-departmental changes (such as improving communication with the billing department) will take more time. SNS s involvement has created a safer environment for many of these cross-departmental actions, but it will take continual work to fully implement some of these recommendations. NAHC noted that the recommendations represented both new insights and a confirmation of what they already knew. They emphasized the value of SNS s role as an external expert, noting that it has helped garner support for the proposed changes. Clinic staff generally agreed with the recommendations, particularly around improving patient registration, the sliding scale fees, and billing processes. However, they also expressed concern that the suggestions focused too much on business aspects, rather than a holistic understanding of the clinic s mission. NAHC felt that it was ultimately SNS s passion for strengthening safety net dental clinics that brought support and buy-in from clinic staff and leadership who may have been wary of outside consultants. As a result, NAHC feels they are actively engaged in enhancing their ability to provide oral health services to those who need them most. Prepared by Harder+Company for the California HealthCare Foundation January

63 Vista Community Clinic Vista Community Clinic (Vista) was founded in 1972 with the mission to provide health care and education to those facing economic, social, and cultural barriers. From its early years operating in a donated space at the local animal shelter and then in an old church building, the clinic has grown to accommodate the increasing community need for comprehensive health services. Since 1997, Vista has grown to a 30,000-square-foot flagship primary care clinic with five additional clinic sites offering a wide range of health services including specialty care for women and teens, geriatric services, pediatric care, family planning, and health education. At-A-Glance FQHC located in northern San Diego County, CA 7 operatories, 1 portable >11,500 visits/year ~20% adult patients 67% Medi-Cal; 20% grants; 8% Healthy Families; 4% self-pay Serves primarily children and pregnant women, mostly lowincome and uninsured Consultant: SNS Most recently, in recognition of the community need for affordable dental care, Vista started providing oral health services at its flagship site. With seven operatories, the new dental clinic aims to serve children and pregnant women from low-income families. As a result of this demonstration project, Vista now also operates a portable oral health program to reach children at neighborhood schools. Recommendations Fully Implemented Institute no-show policy Adopt formal policy regarding treatment of emergencies Create financial and productivity goals Start portable, school-based oral health program Balance the payer and patient mix Increase fee schedule Stabilize front desk and clinic manager staffing Implementation Ongoing Maintain or increase the number of children and pregnant women with Medicaid dental insurance Improve accounts receivable follow-up for self pay patients Educate staff about Medicaid rules and regulations Regular staff meetings Baseline Challenges and Goals As a newly established dental clinic, Vista looked to SNS for guidance on how to create an organized, efficient, and financially stable clinic. This was the first time we did dental. We ve never done dental before and so we are sort of flying by the seat of our pants. Last year we lost $150,000 and this year we made money. Since Vista mostly served pediatric patients, they were not hard-hit by the loss of Medi- Cal adult benefits. However, they wanted practice management consulting to help them build a solid foundation in best practices as they consider expanding into adult care in the future. Recommendations and Outcomes Vista successfully implemented most of SNS s suggestions on policies and procedures as well as goal-setting within 90 days of participation. A major factor in Vista s success with the consulting process was the high level of buy-in among clinic management and dental staff. We wanted to just smooth out the system find out any suggestions [SNS] had to make our day run smoother. Financially, of course, we didn t want to operate at a loss. Prepared by Harder+Company for the California HealthCare Foundation January

64 Establish policies and procedures. One of SNS s recommendations for improving clinic efficiency was to establish a no-show policy which would allow only three consecutive no-shows before a patient is dismissed from the practice. By reducing no-shows, Vista hoped to reduce the need to overbook schedules, thereby reducing staff stress levels. However, this recommendation was not entirely supported by some clinic staff who viewed the policy as requiring unnecessary paperwork. During the implementation phase, clinic management discovered that the new no-show policy was not being fully enforced by staff and have since addressed the issue. They expect even greater reductions in no-show rates moving forward. Since the policy has been fully implemented, the clinic has seen its no-show rate drop from 30 percent to 17 percent. Self-Reported Outcomes Adopt triage process. Vista adopted a formal policy that clearly defines dental emergencies and appropriate level of urgency in scheduling. These policies helped inform front office staff of the proper triage procedures, leading to improved clinic efficiency and patient flow. Set productivity goals. SNS recommended that Vista establish goals to track productivity over time and monitor financial viability. Setting goals and monitoring productivity will allow the clinic to think more strategically about how to maximize clinic time to serve more people. Start a portable oral health program. Prior to this project, Vista applied for an expansion grant to fund a school sealant program. With help from SNS, Vista established a portable school-based dentistry program, allowing them to serve more children and increase productivity. With portable equipment, Vista can locate at schools and make oral health services more accessible to the community. Reflecting on the Project Vista was highly satisfied with the consulting services they received through SNS. They have made recommendations that are logical, that are easily implemented, that have helped us become more efficient and viable. I think that staff satisfaction and patient satisfaction [is good], explained the CEO. Vista had great success in implementing recommendations and completed most of them within 90 days. To Date Streamlined front office operations Reduced no-show rate Increased clinic productivity Increased net revenue Reduced expenses Improved margin Established portable clinic Expected Increase support among staff of new policies and clinic procedures [SNS] evaluated what we were doing, they supported the administration, they gave us recommendations for change, and they also introduced us to the concept of portable dentistry. - Vista CEO While the clinic expressed overall satisfaction with the consulting services, there was some uncertainty on how to attribute the positive changes. Prior to the engagement, Vista already had a number of changes in motion and it was difficult to determine how much of an impact SNS had. We are not losing money anymore, but I don t know what to attribute to the changes that were previously made [before working with SNS], shared the dental director. At the start of the process, clinic-level staff had hoped that the consultants would recommend ways to maintain financial viability while reducing productivity and stress for the clinic. Compared to Prepared by Harder+Company for the California HealthCare Foundation January

65 benchmarks set by the Health Resources and Service Administration (HRSA), Vista was already producing at above-average rates. I think what we were all thinking is that [the consultants] would say, Hey you guys are really working too hard, let s reduce [your workload] That is what the staff wanted and what the doctors were hoping for and that is not the way it went... we were hoping that [management] would listen to an outside source and set realistic productivity expectations. Unfortunately, this issue got lost in the urgency and chaos created by budget cuts and the tough economic environment. It seemed like the initial plan was rather generic and not really as specific to what our clinic was actually doing as we had hoped. - Vista Dental Director Clinic management felt that the consultants could have pushed for deeper change with a more customized approach. The dental director commented, [The recommendations] could have been a little bit more customized for our clinic. I don t know if they were doing too many [clinics] at the same time and it was hard for them to really focus on what was going on with [Vista] and seeing really where we can improve instead of having more of a generic plan Some of the things they were suggesting were things we were already doing. The clinic had the momentum and potential for greater change that was not realized. Overall, Vista highly appreciated the advice and support SNS provided in the project. With plans to expand its dental practice, Vista sought to develop a dental practice model grounded in firm financial footing. Vista s CEO explained, I am not going to expand dental if I lose money, so we have to break even or do better. SNS provided valuable insight and tools that will help Vista move forward. Prepared by Harder+Company for the California HealthCare Foundation January

66 Appendix B: Clinic Attributes and Data Clinic Attributes at Baseline Baseline Self-Reported Measures* 3 rd Quarter Self-Reported Measures* Health Resources and Services Administration Benchmarks 1.7 visits/dentist-hour 13.6 visits/fte dentist per day 2,500-3,200 visits/year per FTE dentist N/A N/A Clinicas de Salud del Pueblo Brawley, CA TA Provider: SNS FQHC 14 operatories, 5 FTE dentists 2.6 visit/dentist-hour 21 visits/fte dentist per day 4,926 visits/year per FTE dentist Margin: $80,260 Net revenue: $516,827 Grants: $27,569 Expenses: $436,567 Visits: 6,032 Pediatric patients: 45.1% No-show rate: 37.9% Wait time: 12 days Margin: -$30,749 Net revenue: $393,545 Grants: $27,323 Expenses: $424,294 Visits: 5,635 Pediatric patients: 60.3% No-show rate: 30.9% Wait time: 3-5 days Community Oral Health Services Salinas, CA TA Provider: SNS Nonprofit mobile clinic 2 mobile vans, 0.7 FTE dentists (1 FTE dentist in 3 rd quarter) 2.4 visits/dentist-hour; 4-5 procedures per visit 19 visits/fte dentist per day Margin: -$113,181 Net revenue: $86,709 Grants: $121,555 Expenses: $199,890 Visits: 1,036 Pediatric patients: 99.9% No-show rate: 22.4% Wait time: 1-7 days Margin: -$91,516 Net revenue: $93,194 Grants: $208,727 Expenses: $184,710 Visits: 1,337 Pediatric patients: 92.4% No-show rate: 17.6% Wait time: 1-7 days County of Marin Dental Clinic San Rafael, CA TA Provider: SNS County clinic 3.5 FTE dentists 3.6 visits/dentist-hour 27 visits/fte dentist per day 4,099 visits/year per FTE dentist Margin: -$595,016 Net revenue: $1,154,806 Grants: $10,000 Expenses: $1,749,822 Visits: 1,879 Pediatric patients: 45.8% No-show rate: 17.7% Wait time: 90 days Margin: -$335,979 Net revenue: $607,137 Grants: $0 Expenses: $943,116 Visits: 1,507 Pediatric patients: 35.3% No-show rate: 25.3% Wait time: 30 days Del Norte Clinics Yuba City, CA TA Provider: Pride Institute FQHC 12 operatories, 4 dentists 3-4 visits/dentist-hour >5,000 visits/year No-shows and cancellations: 40% Pediatric patients: ~46% Data unavailable Inland Behavioral & Health Services San Bernardino, CA TA Provider: SNS FQHC 5 operatories, 1.4 FTE dentists (2 FTE dentists in 3 rd quarter) 1 visit/dentist-hour; 2.2 procedures per visit 9 visits/fte dentist per day 1,491 visits/year per FTE dentist Margin: -$34,776 Net revenue: $119,158 Grants: $0 Expenses: $153,934 Visits: 1,295 Pediatric patients: 38.0% No-show rate: 33.8% Wait time: 21 days Margin: -$63,516 Net revenue: $127,808 Grants: $0 Expenses: $190,862 Visits: 1,412 Pediatric patients: 44.3% No-show rate: 10.4% Wait time: 5 days Prepared by Harder+Company for the California HealthCare Foundation January

67 Clinic Attributes at Baseline Baseline Self-Reported Measures* 3 rd Quarter Self-Reported Measures* La Clínica de la Raza Oakland, CA TA Provider: Pride Institute FQHC 10 operatories, 4 dentists Average of 324 visits/month (~3,888 visits/year) No-shows: 2-6 per day Emergency walk-ins: 5-10 per day Pediatric patients: ~50% Data unavailable Mission Community Hospital San Fernando, CA TA Provider: SNS Hospital-affiliated nonprofit clinic 3 operatories, 1 FTE dentist 1.4 procedures per visit 9 visits/fte dentist per day 1,390 visits/year per FTE dentist <2,000 visits/year Margin: -$21,355 Net revenue: $44,729 Grants: $11,936 Expenses: $66,084 Visits: 497 Pediatric patients: 6.4% No-show rate: 19.3% Wait time: 30 days Margin: -$27,193 Net revenue: $46,943 Grants: $30,381 Expenses: $74,136 Visits: 561 Pediatric patients: 6.3% No-show rate: 11.9% Wait time: days Native American Health Center San Francisco, CA TA Provider: SNS FQHC 6 operatories, 3-4 FTE dentists 1 visit/dentist/hour 9 visits/fte dentist per day 1,969 visits/year per FTE dentist >7,000 visits/year Margin: $56,008 Net revenue: $370,483** Grants: $0 Expenses: $314,475 Visits: 1,620 Pediatric patients: 33.1% No-show rate: 10.0 % Wait time: 30 days Margin: -$188,193 Net revenue: $399,071 Grants: $188,193 Expenses: $587,264 Visits: 1,895 Pediatric patients: 44.5% No-show rate: 36.6% Wait time: 30 days Vista Community Clinic Vista, CA TA Provider: SNS FQHC 7 operatories, 3-4 FTE dentists 2.1 visits/dentist-hour 17 visits/fte dentist per day 4,926 visits/year per FTE dentist >11,500 visits/year Margin: -$42,131 Net revenue: $338,354 Grants: $84,760 Expenses: $380,485 Visits: 3,345 Pediatric patients: 80.0% No-show rate: 41.0% Wait time: 16 days exam, 2 days urgent care Margin: $118,464 Net revenue: $458,625 Grants: $76,767 Expenses: $340,161 Visits: 4,104 Pediatric patients: 83.7% No-show rate: 20.4% Wait time: 20 days exam, 1 day urgent care * Margin and net revenue reported in this table excludes grant funding, which is reported separately. A negative margin indicates that the clinic operated at a loss. Some clinics were able to offset losses using grant funding. ** Baseline (Q0) net revenue for Native American Health Center is unavailable. Therefore, the baseline net revenue reported is from the first quarter of implementation (Q1). All other measures reported are from the true baseline (Q0). Prepared by Harder+Company for the California HealthCare Foundation January

68 Appendix C: Clinic Goals and Outcomes Clinic Goals Strategies Successes Challenges & Concerns Clínicas de Salud del Pueblo Brawley, Calexico, and Mecca, CA TA Provider: SNS Positive changes in billing procedures, quality of care, scheduling, and staff satisfaction. Offer more comprehensive services. Improve financial outlook. Formalize and implement scheduling procedures. Ensure patient payments are collected. Define patient care policy. Increase number of women and children in practice. Better patient flow. Greater Medi-Cal reimbursement. Reduced no-show rate. Increased share of children in patient population. High frustration in past about scheduling. Low staff buy-in from staff and administration. Scheduling changes were unsuccessful, with significant decrease in productivity. Competition from across the border clinics. Community Oral Health Services Salinas, CA TA Provider: SNS To keep clinic doors open. Set up a foundation for long-term growth and sustainability. Learn how to sustain without grant funding. Increase emphasis on treatment (reimbursable services) rather than prevention and education. Strengthen billing and collection practices. Increase fees and implement slidingscale fee structure. Improved margin. Increased productivity. Hired a dental consultant to advise on transition to treatment. Progress toward a more sustainable patient mix. Reduced no-show rate. Significant changes needed to mission, culture, and set-up as they refocus efforts to billable services. Higher costs of operating a mobile clinic. Competition from other community clinics for pediatric patients. County of Marin Dental Clinic San Rafael, CA TA Provider: SNS Gain a fresh pair of eyes regarding clinic operations. Improve scheduling protocols and patient policies. Implement a triage process and eliminate walk-ins. Hired a consultant to oversee quality of care. Improved margin and reduced expenses. Increased clinic efficiency. Reduced stress for clinic staff. Labor unions and county policies limited the clinic s ability to implement incentive programs for dentists, change fee schedules, or require proof of income for service. Del Norte Clinics Oroville, CA TA Provider: Pride Institute Gain a fresh pair of eyes regarding clinic operations. Develop strategies for scheduling. Improve cohesiveness of front office team. Improve scheduling protocols. Clarify front desk duties and train staff. Increase number of pediatric and self-pay patients. Serving more pediatric and self-pay patients. Hired per diem staff as full-time. Upgraded x-ray equipment. Dental director left part way through the process. Loss of federal and state funding required clinic to prioritize financial survival. Project ultimately discontinued. Prepared by Harder+Company for the California HealthCare Foundation January

69 Clinic Goals Strategies Successes Challenges & Concerns Inland Behavioral & Health Services San Bernardino, CA Develop strategies to reduce stress in the clinic operations and improve longterm financial viability. Increase fees, with strategy to educate patients on the value of the services they receive. Implement a triage process for walk-ins. Improve staffing to maximize patient flow and revenue. Avoided lay-offs despite elimination of adult Medi-Cal dental benefits (serves mostly adult patients). Improved patient flow. Significantly reduced no-show rate. None cited. The clinic implemented recommendations with significant success. Educate staff to monitor Phase I treatment completion. La Clínica de la Raza Oakland, CA TA Provider: Pride Institute Improve clinic efficiency and organization. Enhance staff and student training. Improve staff teamwork and accountability. Enhance staff training. Update clinic fees. Improved internal communication. Defined staff roles more clearly. Fees to be increased in the next fiscal year. Clinic did not have a front office manager. Low buy-in from staff charged with implementation. Mission Community Hospital San Fernando, CA TA Provider: SNS Formalize policies and procedures. Respond to cuts in grant funding by maximizing revenue. Implement sliding fee scale. Formalize protocols for eligibility, scheduling, billing and payment. Define scope of services. Acquired new equipment. Increased number of patients paying upfront. Began implementing designated access scheduling. SNS did not fully understand clinic s mission to serve those most in need (adults). Significant competition for pediatric patients. Upgrade dental equipment. Reduced no-show rate. Native American Health Center San Francisco, CA TA Provider: SNS Improve efficiency and standardize procedures. Benchmark policies and procedures. Expand pediatric services. Manage executive level anxiety about cuts to dental Medi-Cal. Increase fees and modify sliding scale fee schedule. Increase number of pediatric and pregnant women patients. Streamline front desk operations. Move forward with portable clinics. Tripled monthly cash and insurance collections. Increased productivity and margin. Increased share of children in patient population. Served over 300 lowincome children at 11 new portable clinics. Centralized billing department made some changes difficult to implement, and created barriers to data reports. Administration has been resistant to change, but SNS has mitigated that resistance. Vista Community Clinic Vista, CA TA Provider: SNS Medical FQHC looking to expand into dental. Looking for best practices to build an efficient and financially sustainable clinic. Formal policies and procedures for noshows and emergencies. Increase fee schedule. Sustainable patient mix. Productivity goals. Streamlined front office operations. Increased clinic productivity and margin. Established a portable clinic. Significantly reduced no-show rate. Recommendations were easy to implement for Vista. They would have appreciated deeper consultation on where they could improve instead of a generic plan. Prepared by Harder+Company for the California HealthCare Foundation January

70 Appendix D: Clinic Communities Clinic Location County Health Ranking in California 1 County Population Risk Factors 2,3 Clinicas de Salud del Pueblo Brawley, CA Imperial County Rural #39 healthy outcomes #54 healthy factors #53 clinical care 22% adults uninsured 22% poverty rate 287 ED dental visits/1,000 people Community Oral Health Services Salinas, CA Monterey County Rural #16 healthy outcomes #29 healthy factors #33 clinical care 24% adults uninsured 13% poverty rate 230 ED dental visits/1,000 people County of Marin Dental Clinic San Rafael, CA Marin County Urban #1 healthy outcomes #1 healthy factors #1 clinical care 17% adults uninsured 7% poverty rate 180 ED dental visits/1,000 people Del Norte Clinics Yuba City, CA Sutter County Rural #21 healthy outcomes #35 healthy factors #35 clinical care 20% adults uninsured 16% poverty rate 196 ED dental visits/1,000 people Inland Behavioral & Health Services San Bernardino, CA San Bernardino County Urban #45 healthy outcomes #50 healthy factors #54 clinical care 23% adults uninsured 15% poverty rate 300 ED dental visits/1,000 people La Clínica de la Raza Oakland, CA Alameda County Urban #23 healthy outcomes #15 healthy factors #24 clinical care 16% adults uninsured 10% poverty rate 194 ED dental visits/1,000 people Mission Community Hospital San Fernando, CA Los Angeles County Urban #26 healthy outcomes #44 healthy factors #52 clinical care 23% adults uninsured 15% poverty rate 128 ED dental visits/1,000 people Native American Health Center San Francisco, CA San Francisco County Urban #24 healthy outcomes #12 healthy factors #5 clinical care 18% adults uninsured 11% poverty rate 158 ED dental visits/1,000 people Vista Community Clinic Vista, CA San Diego County Urban #15 healthy outcomes #19 healthy factors #20 clinical care 22% adults uninsured 13% poverty rate 150 ED dental visits/1,000 people 1 County rankings are out of 56 total counties in California. Rank of #1 indicates the healthiest county, while rank of #56 indicates the least healthy county. Source: 2010 County Health Rankings ( accessed 2/26/2010). 2 Statewide average of 21% adults uninsured, 13% poverty rate, and 222 emergency department (ED) dental visits per 1,000 people. Sources: 2010 County Health Rankings ( accessed 2/26/2010); ERS/USDA 2008 County Poverty Rates ( site accessed 2/26/2010); California HealthCare Foundation. Emergency Department Visits for Preventable Dental Conditions in California, Emergency department (ED) dental visits are often preventable with proper dental care. Prepared by Harder+Company for the California HealthCare Foundation January

71 Appendix E: Interview Participants Demonstration Clinics Clinicas de Salud del Pueblo Brian Shue, Dental Director (primary) Jean Fisher, Chief Operating Officer Yolanda Paz, Clinic Manager at Brawley Community Oral Health Services Debi Diaz, Executive Director (primary) Hugo Ferlito, Dental Director Ray Stewart, Consultant County of Marin Dental Services Shirley Watt, Program Director (primary) James Villella, Program Director (primary) Karen Wuopio, Public Health Program Manager Del Norte Clinics Mark Woolery, Chief Financial Officer (primary) Charles Marshall, Dental Director Theresa Thornton, Clinic Manager at Oroville Inland Behavioral and Health Services James Walter, Health Administrator (primary) Temetry Lindsay, Chief Executive Officer John Anderson, Dental Director La Clínica de la Raza Monica MacVane-Pearson, Associate Dental Director (primary) Ariane Terlet, Dental Director Patricia Gonzales, Lead Assistant Jasmine Rios, Lead Assistant Mission Community Hospital Audrey Simons, Clinic Administrator (primary) Alexis Gutierrez, Dental Director Jerome Selinger, Senior Consultant for Development Margarita Velasquez, Office Manager Native American Health Center Carolyn Brown, Dental Director (primary) Charlene Harrison, Director of Third Party Relations Eulalia Valerio, Director of Projects and Evaluation Lucy Wright, Patient Navigator Vista Community Clinic Barbara Mannino, Chief Executive Officer (primary) Dina O Donnell, Dental Director Bonnie Torres, Dental Manager Prepared by Harder+Company for the California HealthCare Foundation January

72 Stakeholders Oral Health Organizations Patricia Baker, Connecticut Health Foundation Peter A. DuBois, California Dental Association Katie Eyes, Blue Cross Blue Shield Foundation of North Carolina Larry Hill, Ohio Safety Net Project Dawn Miller, Sisters of Charity Foundation of Canton Amanda Stangis, California Primary Care Association Schools of Dentistry Nelson Artiga-Diaz, University of California San Francisco School of Dentistry Roseann Mulligan, University of Southern California School of Dentistry Paul Richardson, Loma Linda University School of Dentistry Non-Participating Safety Net Dental Clinics Dominic Cazalaro, Contra Costa Regional Medical Center Vicky Deloney, Sacramento County Dental Clinic Inez Leonard, Sacramento County Dental Clinic John Pham, Eisner Pediatric and Family Medical Center Franklin Pierce, Shasta Community Health Dental Center Jared Simpson, Clinica Sierra Vista Carter Wright, Open Door Community Health Centers Potential Partners Jay Anderson, Health Resources and Services Administration Cecilia Echeverria, The California Endowment Moira Kenny, First 5 Association of California Colleen Lampron, National Network for Oral Health Access Jon Roth, California Dental Association Foundation Program Staff and Consultants Dori Bingham, Safety Net Solutions Mark Doherty, Safety Net Solutions Len Finocchio, California HealthCare Foundation Paul Glassman, California Pipeline Program administered at University of the Pacific Mary Lynn Wheaton, Pride Institute Prepared by Harder+Company for the California HealthCare Foundation January

73 Harder+Company Community Research is a comprehensive social research and planning firm with offices in San Francisco, Davis, San Diego, and Los Angeles, California. Our mission is to strengthen social services, improve decision-making, and spur policy development by providing quality research, technical assistance, and strategic planning services. Since our founding in 1986, we have worked with foundations, government and nonprofits throughout California and the country. Our success results from delivering services that contribute to positive social impact in the lives of vulnerable people and communities. harderco.com Prepared by Harder+Company for the California HealthCare Foundation January