REGISTERED DENTAL HYGIENISTS IN ALTERNATIVE PRACTICE IN CALIFORNIA, 2009 DESCRIPTIVE REPORT

REGISTERED DENTAL HYGIENISTS IN ALTERNATIVE PRACTICE IN CALIFORNIA, 2009 DESCRIPTIVE REPORT Cynthia Wides, MA Tim Bates, MPP Elizabeth Mertz, PhD, MA December 2011

Acknowledgements This project was completed with support by a grant from the Center for Special Care at the Arthur A. Dugoni School of Dentistry, University of the Pacific. The project was also supported by Award # P30DE020752 from the National Institute of Dental & Craniofacial Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Dental & Craniofacial Research or the National Institutes of Health. Special thanks to Dr. Paul Glassman, DDS, MA, MBA; Maureen Harrington, MPH; and Maysa Namakian, MPH for assistance in final report review. Suggested Citation Wides, C., Bates, T., and Mertz, E. Registered Dental Hygienists in Alternative Practice in California, 2009 Descriptive Report. San Francisco, CA: Center for the Health Professions, University of California, San Francisco. 2011. University of California, San Francisco 3333 California Street, Suite 410 San Francisco, CA 94118 http://futurehealth.ucsf.edu Copyright 2011. Center for the Health Professions

Table of Contents INTRODUCTION... 3 REGISTERED DENTAL HYGIENISTS IN ALTERNATIVE PRACTICE... 4 DEMOGRAPHIC CHARACTERISTICS... 4 EDUCATION AND LICENSURE... 6 EMPLOYMENT IN DENTAL HYGIENE... 10 Employment as a Registered Dental Hygienist... 11 RDHAP PRACTICE CHARACTERISTICS... 12 RDHAP Employment of Personnel... 12 RDHAPs as Employees... 13 RDHAP Practice Setting and Hours... 13 RDHAP Patient Characteristics... 16 RDHAP Practice Finance and Economics... 18 RDHAP Professional Networks and Collaboration... 21 RDHAP PROFESSIONAL DEVELOPMENT AND ADVANCEMENT... 25 RDHAP Motivation to Practice... 25 RDHAP Job Satisfaction and Barriers to Practice... 25 STUDY LIMITATIONS... 28 REFERENCES... 28

INTRODUCTION Background to Study In 1998, California officially recognized a new dental health profession: the Registered Dental Hygienist in Alternative Practice (RDHAP). To become licensed as a RDHAP, California requires Registered Dental Hygienists (RDH) to a) have a minimum of 2,000 hours of clinical hygiene practice in California during the immediately preceding 36 months, b) hold a bachelor's degree or its equivalent, and c) complete a 150-hour education program approved by the California Board. These RDHs are then eligible to take a written law and ethics exam prescribed by the Dental Board, the passage of which leads to RDHAP licensure. RDHAPs may practice without the supervision of a dentist in private homes, schools, residential care facilities and other institutions, and in Dental Health Professional Shortage Areas. However, to gain licensure, RDHAPs are required to have a dentist of record, on file with the Dental Hygiene Committee of California for use in consultations and in emergencies. New workforce models in dentistry are being explored as potential solutions to improving the dental care delivery system for underserved populations(mertz and Finocchio 2010). Potential solutions cover a wide range of proposed models, but to date, only a few new models have been tested in various states around the country(gehshan 2009; Mertz and Mouradian 2009). This study builds from previous efforts to understand the history, development and deployment of RDHAPs into the field of dentistry(mertz 2007; Mertz 2008; Mertz 2008; Mertz and Glassman 2011), and provides a first look at the RDHAP model of care delivery in California. Survey Design This report was created from data collected by a census survey of all 244 RDHAPs licensed in California. The license file of RDHAPs was obtained from the Department of Consumer Affairs of California in June 2009, and the survey was conducted in the fall of 2009. The RDHAPs were surveyed about their demographics, education, professional activities, practice data (including patients, settings, finances), as well as issues of professional development and advancement. The survey s response rate was 72% (n=176). Of respondents, 92.6% were active licenses, and, of those, 1.1% were residing out of state at the time of the survey. The un-weighted survey responses were analyzed using descriptive statistical techniques. 3

REGISTERED DENTAL HYGIENISTS IN ALTERNATIVE PRACTICE Demographic Characteristics Age: The following section reports the demographic characteristics of all RDHAPs who responded to the survey (n=176) in 2009. Approximately 97% of RDHAPs are female, with an average age of 48. The largest portion of respondents was between 45-54 years old, followed by those ages 35-44. Fewer than 5% of respondents were age 65 or older, and none were under the age of 25. Race/Ethnicity: The majority of RDHAPs identify themselves as non-hispanic whites (68.8%), which is higher than the distribution of non-hispanic whites in the general population (42%) in California (California Department of Finance 2010). Approximately 13.1% are of Hispanic origin, 5.7% identified as Asian, and 2.3% identified as African American. The other groups comprising the remaining 2.3% of the respondents include Native American, Native Hawaiian, Asian Pacific Islanders, Filipino, Iranian, and mixed-race individuals. 4

Language Skills: RDHAPs speak a wide range of languages with their patients. A total of 43% (n=76) of RDHAPs reported that they could functionally communicate with their patients in one language other than English. An additional 4% (n=7) reported using two languages other than English with their patients, bringing the total to 47% (n=83). Thirteen languages, other than English, are spoken by 83 RDHAPs. Spanish was the most commonly cited language (n=51), followed by the European languages (French, German, and Italian) (n=7), Farsi is spoken with patients by 7% (n=6) of RDHAPs. Russian, Tagalog, Chinese, Sign language, and Hindi are each used with clients by fewer than 5 RDHAPs. Not reflected in the chart are Armenian, Indonesian, and Vietnamese, which were each listed by only one RDHAP. Summary: Registered Dental Hygienists in Alternative Practice (RDHAP) are demographically similar to Registered Dental Hygienists (RDH) in gender, age, and racial/ethnic distribution. More than 90% of RDHAPs are women over the age of 35 and the average age is 48. Relative to the racial/ethnic makeup of the California population, RDHAPs are more likely to identify as white, non-hispanic (69%). Almost half of RDHAPs speak a language other than English in their clinical practice, with Spanish being most frequently cited of these languages. 5

Education and Licensure Education and Licensure Requirements: The independent dental hygienist was originally developed and tested through the Health Workforce Pilot Program (HWPP) in California. The RDHs who completed the pilot project were granted licensure as RDHAPs in 1998. RDHs who did not complete the pilot project can gain licensure as RDHAP by fulfilling the requirements established by the California Dental Board. Among these requirements is the completion of a baccalaureate degree in any field or the completion of baccalaureate-equivalent coursework (120 units). This requirement results in RDHAPs having a higher level educational achievement than the general population of RDHs in California. Individuals who gained AP licensure through the pilot program along with those who have baccalaureate-equivalency are reflected in the survey results. Highest Educational Achieved: A total of 176 RDHAPs responded to the survey s Education and Licensure section and are included in the analysis. Only 1% of RDHAPs hold a Certificate, while a more than a third of hold an associate degree. More than half of RDHAPs have a baccalaureate degree, and 12.5% have attained a masters or doctoral degree. Response rates by training program: Currently, there are only two training programs in California for RDHs seeking AP licensure: the University of the Pacific (UOP) in San Francisco and West Los Angeles College (WLAC) in Los Angeles. As of June 2009, 244 RDHAPs were licensed. Of these licensees, UOP trained 57.4% (n=140), WLAC trained 35.7% (n=87), and 6.9% (n=17) were granted their AP licensure through their participation in the HWPP project. Of those RDHAPs who responded to our survey, 59.7% (n=105) were trained at UOP, 34.1% (n=60) were trained at WLAC and 6.3% (n=11) were HMPP participants. Therefore, the survey responses closely match the population of RDHAPs by location of RDHAP training. The 176 RDHAPs who responded to this survey represent 72% of all licensed RDHAPs. 6

RDHAP Educational Program Choice and Experience: Just over a third of RDHAPs reported learning of their training programs through word of mouth. The dental hygiene association was the second most common source of information on RDHAP training programs, followed by advertisements in dental health journals. Very few respondents reported learning about the RDHAP training program from a dentist or a direct mailing. RDHAPs reported a wide variation of reasons for choosing their AP program. The most common reason was program location (47.3%), followed by desire for on-line classes (33%). Program reputation was cited by 20% of RDHAPs, some of whom to attend a University while others preferred some specific curriculum component or professor. Being a previous graduate of the school or seeking a shorter program length were each cited by 2%. An additional 5 individuals gave other reasons, including receiving acceptance first or not knowing about other programs. Reason for Choosing RDHAP Program Frequency Percent Total Respondents 148 100% Location of program 70 47.3% Online classes 49 33.1% Reputation of program 30 20.3% In-person classes 11 7.4% Program cost 4 2.7% Recommendation from a friend 4 2.7% Alma mater 3 2.0% Program length 3 2.0% 7

Overall, almost 90% (n=158) of RDHAPs reported being Somewhat Satisfied or Very Satisfied with their training program. Only 10% (n=18) of respondents were Somewhat or Very Unsatisfied. RDHAPs were asked to report areas of additional training that would have been useful to prepare them for RDHAP practice. Four of the top five most frequently selected options for additional training were related to running a business; however, current legislation limits the RDHAP curriculum to a maximum of 25% of training hours focused on business management skills. Billing insurance and/or Denti-Cal was selected by 70% (n=120) of RDHAPs. Cognitive assessment and Health education were the least frequently chosen. RDHAPs also suggested Ergonomics/working with the disabled, Legal issues/contracts, and Computer resources/software as other needed training areas. Additional training that would have been useful for RDHAP practice Frequency Percent Total Respondents 172 100% Billing insurance and/or Denti-Cal 120 69.8% Marketing and outreach 95 55.2% General business planning 81 47.1% Financial practice mgmt 70 40.7% Additional field work/shadowing 68 39.5% Mobile equipment 54 31.4% Adaptation of procedures to alternative settings 51 29.7% Interdisciplinary health team interactions 36 20.9% Infection control in alternative settings 35 20.3% Behavior modification/patient compliance 22 12.8% Personnel mgmt. 19 11.0% Program planning and evaluation 16 9.3% Medical emergency training 13 7.6% (continued on following page) 8

Additional training that would have been useful for RDHAP practice (cont d) Frequency Percent Total Respondents 172 100% Patient assessment 11 6.4% Other (various) 10 5.8% Communication/interpersonal 10 5.8% Cultural fluency 6 3.5% Patho-physiology 6 3.5% No additional training needed 6 3.5% Ergonomics/working with the disabled 5 2.9% Cognitive assessment 4 2.3% Legal issues/contracts 3 1.7% Health education 2 1.2% Computer resources/software 2 1.2% Summary: Approximately two-third of RDHAPs hold a Bachelor s degree or higher. Word of mouth was the most common way in which RDHAPs learned about their training program, and program location was the most common reason reported for choosing an AP program. Approximately 57% of licensees were trained at UOP, 35% at WLCA and the rest were participants in the HMPP training program. Nearly 90% of RDHAPs reported being Satisfied or Very satisfied with their training program. Business and financial management accounted for four of the five most frequently requested topics for additional training. 9

Employment in Dental Hygiene Active vs. Inactive Dental Hygiene Practice: RDHAPs are required to hold active RDH licenses, so they are able to practice dental hygiene in either capacity. However, holding an active license does not mean that one is actively in practice. We asked the survey participants if they were currently practicing dental hygiene in California in ANY capacity. N=2 were no longer living in California, and therefore not included in any analysis of practice activities. The overwhelming majority (n=162) of respondents are actively practicing dental hygiene in California in either as an RDH or as an RDHAP. Inactive RDHAPs were asked why they left dental hygiene practice. Only one RDHAP selected Dissatisfaction with career choice as the primary reason for leaving dental hygiene practice. Health issues, retirement, further education, and other were each selected by two RDHAPs. Of the 6.9% (n=12) licensed RDHAPS who were not currently practicing in 2009, 2 responded that they intend to return to active practice within the next 5 years. Primary Reason for Leaving Practice Frequency Job-related injury or disability 2 Health/physical reasons (not job related) 2 Retirement 2 Dissatisfaction with career choice 1 Seeking further education 2 Other 2 Total 11 RDHAPs who are currently practicing dental hygiene in any capacity (n=162) were asked how many more years they intend to continue to do so. The largest share of these hygienists, almost 60% (n=93), indicated that they expect to continue practicing for 10 years or more. Only 2.5% (n=4) expect to continue practicing for less than 2 years. 10

Employment as a Registered Dental Hygienist Traditional RDH Employment: Many licensed RDHAPs maintain employment in a traditional dental hygiene practice in additional to and sometimes instead of practicing under their AP licensure. Of the 162 respondents who are currently practicing dental hygiene, 83% (n=134) are employed as an RDH, and 87% (n=116) of these individuals work in a private dental practice. The RDHAPs who have continued to practice in their capacity as an RDH have been employed at their current RDH work location for an average of 9.4 years (median=8 years). RDHAPs work as RDHs an average of 24 hours per week (median=24 hours), earn an average of $50 per hour (median=$50), and 45% (n=60) of these RDHAPs receive a benefits package as part of RDH employment. More than 75% of RDHAPs (n=103) were employed an as RDH in the same setting prior to completing their RDHAP licensure, and close to 60% (n=77) are currently employed in this setting by their dentist of record. Summary: The majority (93%) of RDHAPs report active practice in dental hygiene, and of those currently not practicing, 25% intend to return. Close to 60% of RDHAPs who are currently in active practice intend to remain in the field for 10 years or longer, indicating high and long-term labor market participation by this group of providers. The large majority (82%) of respondents maintain employment as an RDH, usually in a private practice. The average length of this employment is more than 9 years, entails 24 hours of work per week at an average rate of $50 per hour, indicating that RDHAPs are continuing a significant amount of work as RDHs in addition to developing their RDHAP practices. 11

RDHAP Practice Characteristics Licensed RDHAPs practice in their capacity as RDHAPs in a wide variety of settings under a number of arrangements. Almost three-quarters (n=118) of those RDHAPs holding an active license are currently working as an RDHAP in California. The following section details RDHAP practice patterns. RDHAP Employment of Personnel The majority (80.5%) of currently practicing RDHAPs do not employ anyone in their practice. Of the 19.5% (n=23) who employ staff in their RDHAP practice, 16 reported employing only one type of employee. Another 5 reported employing two types of employees, and only two reported employing 3 types of employees. Dental assistants were the most commonly reported type of employee, followed by clerical assistants. Only 2 RDHAPs reported employing other RDHAPs and both of these employed additional types of employee. Distribution of employees of RDHAPs Frequency Dental Assistant only 8 Clerical Assistant only 7 Dental Assistant & Clerical Assistant 3 RDHAP, Dental Assistant, Clerical Assistant 1 Dental Assistant, Clerical Assistant, and Transcriptionist 1 RDHAP & Dental Assistant 1 Clerical Assistant & Equipment Assistant 1 Other Assistant 1 Total 23 12

RDHAPs as Employees Most respondents are not employed by anyone else in their capacity as RDHAP. Of the 21% (n=23) who are employed as an RDHAP, the majority (n=19) are employed by an agency or organization, while five reported being employed by another RDHAP, and one reported being employed by a dentist. RDHAP Practice Setting and Hours RDHAPs provide care in a wide variety of settings; however the number of days per week, the hours per day, as well as the number of patients they treat in each setting varies widely. RDHAP practice settings: Close to 60% of respondents reported working in residences of the homebound, residential facility/assisted living, and nursing home/snf, although the RDHAPs work relatively few days per week and hours per day in these settings. The 15 RDHAPs working in their own private offices in Dental Health Professional Shortage Areas (DHPSAs) reported the highest average hours per day, but on average work only 2 days per week in that setting. Other settings included WIC sites, lowincome housing facility, health fairs, and similar settings. Across all settings, the average number of hours worked per day was 5.3. RDHAP Practice Settings N % Residences of the homebound 72 61.0% Residential facility 70 59.3% Nursing home/skilled Nursing Facility 69 58.5% Schools 25 21.2% Avg. # days/week (range) 0.9 (.04 3) 0.9 (.08-3) 1.5 (.25 5) 1.6 (.5 4) Avg. # hours/day (range) 3.0 (.5 8) 4.0 (.5 8) 5.3 (.5 11) 5.6 (.5 12) (continued on following page) 13

RDHAP Practice Settings (cont d) N % Other 16 13.6% Office in Dental Health Professional Shortage Area (DHPSA) 15 12.7% Hospital 11 9.3% Other institution 9 7.6% Home health 7 5.9% Public health clinic 7 5.9% Community center 6 5.1% Federal /state /tribal institution 5 4.2% Community/migrant health clinic 5 4.2% Avg. # days/week (range) 1.2 (.1 4) 2.0 (.25 4) 0.8 (.25 1) 1.4 (.5 2.5) 1.0 (1.00) 0.6 (.42 1) 1.0 (.083 2) 0.6 (.33 1) 1.0 (1.00) Avg. # hours/day (range) 4.8 (1 8) 7.4 (4 15) 4.3 (1 7.5) 6.7 (4 8) 4.0 (4.00) 5.6 (2-10) 5.4 (.1 10) 5.5 (1 10) 6.6 (6-8) Patients by Setting: The highest average number of patients per day was seen in school settings, followed by public health clinics and community centers. In all settings except for schools, RDHAPs estimated that more than 50% of their patients had no other usual source of dental care. Employment setting Avg. # patients/day % patients without other dental care Schools 27.9 43.9% Public health clinic 12.7 73.3% Community center 12.3 80.8% Community/migrant health clinic 11.3 76.0% Fed/St/Tribal institution 9.0 61.3% Office in dental professional shortage area 6.7 51.8% Nursing home/snf 6.4 78.8% Other institution 5.0 68.1% Home health 4.0 71. 7% Residential facility 3.9 67.8% Hospital 3.3 65.1% Residences of the homebound 2.3 77.3% 14

RDHAP practice activities: Of the 118 RDHAPs in practice in California, 91 (77%) provided estimates of their typical practice week hours. These RDHAPs reported working an average of 20 hours per week, with a median of 16 and a range of (0.5-68). While RDHAPs spend an average of 24 hours per week in traditional RDH employment, and an average of 20 hours per week in AP practice, the proportion of hours spent in AP practice is higher over the length of time since completion of AP licensure. The average proportion of hours RDHAPs spend in AP practice per week is 34% across all RDHAPs, with a range of 0 to 100%. While 70% of those licensed through the HMPP program reported spending 50% or more of their total practice hours in AP Practice, none of the graduates in 2009 reported the same AP practice hours worked. The most frequently reported activity was direct patient care, which was reported by almost 95% (n=90) of RDHAPs. Direct patient care also accounted for the highest average number of hours per week. Administrative activities, case management, and patient behavior management were also reported by more than half of all RDHAPs. Only 11 RDHAPs (11.5%) reported any hours teaching, but, for those who teach, teaching accounted for an average of 6 hours per week. Teaching, other, and research were the least often reported activity hours. Most commonly, RDHAPs identified activities reported as other hours as advocacy activities including public speaking, writing, team or coalition building, and networking. Activity Reported (n=91) % RDHAPs per activity Avg. hours per week Avg. hours per week if > 0 for the activity Direct patient care 94.5% 11.0 17.2 Administration 71.4% 3.8 5.4 Case management 62.6% 2.0 3.2 Public health education 34.1% 1.3 3.8 Patient behavior management 51.6% 1.0 2.0 Teaching 11.0%.6 5.8 Other 8.8%.2 2.6 Research 3.3%.1 1.7 15

RDHAP Patient Characteristics Communication with patients: Seventy-eight RDHAPs reported language barriers in communication with their patients. These barriers were reported with a mean of 25% and a median of 10% of these RDHAPs patients. RDHAP Patient Composition: Of the 118 active RDHAPs, 81% (n=96) provided estimates of the composition of their patient s race/ethnicity. The racial/ethnic composition of RDHAPs patient population is shown here as it compares to the population of California(California Department of Finance 2010). White and Hispanic patients represent the largest share of patients treated by RDHAPs. White patients are overrepresented in RDHAPs patient population relative to that of California, as are African American, other, and Native American patients. RDHAPs were not given space in the survey to identify the groups representing other. Hispanic and Asian-Pacific Islander patients are under-represented as compared to the distribution of the population of California. 16

RDHAPs provided estimates of their patients ages. The distribution of RDHAPs patient population by age is shown as it compares to the distribution of California s population(california Health Interview Survey (CHIS) 2009). Relative to California s population, patients over age 65 are over-represented, while patients between the ages 18-64 are under-represented. Eighty-six percent (n=102) of our survey respondents with an active RDHAP practice in California reported treating at least one patient group with some type of disability. In their practices, RDHAPs treat patients with a wide variety of physical and mental disabilities. Because many of these patients have more than one disability diagnosis, the averages shown in the table do not total to 100%. Medically compromised patients accounted for an estimated 67% of the RDHAPs patients, followed by physically disabled patients, who were estimated to comprise 50% of patients. Patients characterized as mentally ill, developmentally disabled, or severe behavioral management challenges each accounted for less 30% of patients treated by RDHAPs. 17

RDHAPs estimates of their patients insurance coverage indicates that public assistance programs, such as Denti-Cal are the largest source of dental health coverage used by their patients. On average, just over half of RDHAP patients are covered by public insurance, a third are uninsured, and only a tenth have private insurance coverage. An additional 15 RDHAPs responded that they did not know the insurance coverage status of their patients. Summary: Most RDHAPs work independently in their RDHAP practices. RDHAPs practice hours vary across settings. They see the highest number of patients per day in schools. In almost all settings, RDHAPs estimate that more than 50% of their patients have no other source of dental care. RDHAPs work an average of 20 hours per week in their AP practice and spend the bulk of those hours providing direct patient care. Over the time since completion of AP licensure, the proportion of hours spent in AP practice increases relative to hours spent in traditional RDH practice. Seventy-eight RDHAPs reported having some patients with whom they have a language barrier. Latino and Asian/Pacific Islander patients tend to be underrepresented in AP practice relative to the population of California, while people age 65 and older are overrepresented. Most RDHAPs treat patients who are diagnosed with some type of disability. RDHAP Practice Finance and Economics RDHAP Start Up Expenses: Only 8% (n=9) RDHAPs reported that they did not have any practice start-up expenses. Among RDHAPs who reported practice start-up expenses (n=98), about half 53% (n=52) have paid them off. As expected, over time a higher percentage of RDHAPs pay off these start-up costs 18

RDHAP Income and Sources: The average net annual income reported across RDHAP practices was $30,000 per year. Yet, the median annual income reported from RDHAP practice was $15,500. So, while there are a relatively few high earners, the largest share of RDHAPs (n=30) earned $15,500 or less from their RDHAP practice in the previous year. 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 39.5% Reported Annual Income from RDHAP Practice (n=76) 22.4% 9.2% 9.2% 19.7% $1-15,000 $15,001-30,000 $30,001-45,000 $45,001-60,000 $60,001 + Practicing RDHAPs who filed a tax return in 2008 reported on the average percent of gross receipts by payment category. On average, 43.8% of gross receipts were received from public insurance, followed by 37.9% from direct payment/self pay. A smaller average portion of gross receipts in RDHAP practices comes from private insurance (7.7%) or other sources (10.3%). Almost no gross receipts were received from managed care. RDHAP Billing Practices and Fee Structure: Sixty percent (n=71) of practicing RDHAPs reported providing discounted or sliding scale fees for patients who are uninsured or unable to pay for services. RDHAPs reported that a mean of 36% percent of their patients qualified for these discounts, with a median of 25%. 19

The majority (73%) of RDHAPs reported using a standard fee schedule when billing for services. Of these providers, approximately 77% utilize a procedure based fee schedules, while 23% reported using a flat fee schedule. Of RDHAPs with a standard fee schedule, 44.7% reported that their fee schedule is lower than that generally found in a private dental office. 35.3% reported that their fee schedule was the same as that in a private dental office, and 20% of RDHAPs reported that their fee schedule is higher. Average RDHAP Procedure Fees: Just as there is wide variation in practice settings and patient type and volume of RDHAP practices, there is also a wide variation around the average fees charged by RDHAPs for their services. The average fee reported for Root planning (one quadrant) is $149.00, with a range of $45- $275. Fluoride application/varnish averaged as the lowest cost service at $24.40, with a range of $5-75. Summary: Most RDHAPs have some expense in starting up their AP practice, but those in practice for longer amounts of time are more likely to have paid off these expenses. The average net annual income from AP practice is $30,000, though the largest share of RDHAPs (40%) earn less than $15,500 per year from the AP practice. RDHAPs report that most of their patients receive some type of public insurance, and 60% report providing some type of sliding scale or discounted fee system for their patients. There is a wide variation in the fees charged by RDHAPs for individual services. 20

RDHAP Professional Networks and Collaboration RDHAP Referrals and Consultations: When a patient needs dental treatment, on average, RDHAPs refer 30% of their patients to a dentist with whom the patient is already established. Approximately 20% of their patients are referred to the RDHAP s dentist of record. Referrals to other sources of dental care included referrals to facility dentists, mobile dentists, and specialists. RDHAPs indicated that they could not get a referral when needed for an average of 12% of their patients, and 11% of patients were referred to a new dentist with whom the patient was not yet established. Only 9% of patients were referred to community clinics by RDHAP for further dental care. A dentist of record agreement between an RDHAP and a dentist is required for RDHAP licensure to ensure a source for consultation and referrals for the RDHAP. The majority of RDHAPs maintain some type of regular contact with their dentist of record. The most frequently reported contacts with the dentist of record included consultation (50.8%), employment (31.4%), regular referrals, (28.0%) and emergency referrals (28.0%). Approximately 18% (n=21) of RDHAP indicated that they have no interactions with their dentist of record. The most common reason cited for this was that the dentist moved and was no longer available. Others noted that they were contractually obligated to use an internal referral in the context of their place of employment. An additional 8.5% (n=10) listed other interactions. 21

RDHAPs were asked how easy it is to refer their patients to a dentist willing to treat them. Despite most providers having ongoing contact with their dentist of record, only 52.4% (n=54) reported that it is easy or somewhat easy to refer patients to a dentist who is willing to see them while 48.6% (n=49) felt it difficult or somewhat difficult. RDHAPs are allowed to provide services to patients for 18 months, but the continuation of services after this period of time requires the RDHAP to obtain a prescription for dental hygiene services from a dentist or a physician. Of the RDHAPs reporting the level of difficulty they expereinced in getting a prescription to contiue providing dental hygiene services, 67% (n=55) felt it was is easy or somewhat easy to get a prescription. Only 33% (n=27) found it difficult or somewhat difficult to do so. Ability to Refer Patients to a Dentist (n=103) Ability to Obtain Prescrition for Continuation of Care Beyond 18 Months (n=82) Difficult, 47.6% Easy, 52.4% Difficult, 32.9% Easy, 67.1% RDHAP Interdisciplinary Interactions: RDHAPs interact with a wide array of health care professionals in their practices through referrals (both to and from other providers), collaborating in patient care, and in various adminstrative capacities. When they identified the professionals to whom they refer their patients, dental specialists were the most frequently cited (77%), followed by physicians (39%). RDHAP least commonly refer patients to health aids (6.1%) and pharmacists (1.5%). Percent of RDHAPs who Make Referrals to Each Provider Type (n=66) Provider Type % RDHAPs Dental Specialist 77.3% Physician 39.4% Social Worker 24.2% Physician Assistant 15.2% Agency Manager 13.6% Nurse Practitioner 10.6% Registered Nurse 9.1% Nutritionist 7.6% Health Aid 6.1% Pharmacist 1.5% In examining the professionals from whom RDHAPs receive patient referrals, social workers and agency managers emerged as the most frequently cited, with close to 60% of RDHAPs reporting referrals from each of these professionals. Pharmacists (1.6%) are again the least common source of referrals for RDHAPs. 22

Percent of RDHAPs who Receive Referrals from Each Provider Type (n=61) Provider Type % RDHAPs Social Worker 57.4% Agency Manager 57.4% Physician 44.3% Dental Specialist 39.3% Registered Nurse 31.1% Physician Assistant 21.3% Nurse Practitioner 21.3% Nutritionist 9.8% Health Aid 9.8% Pharmacist 1.6% RDHAPs identified social workers (52.7%) and physicians (51.4%) as the professionals with whom they most frequently collaborate, followed closely by dental specialists (45.9%). Collaboration or coordination of patient care with pharmacists (5.4%) is quite infrequent; however, health aids are cited as collaborators by almost 30% of RDHAPs. While health aids play no significant role in referring to or receiving referrals from RDHAPs, they do appear to participate in the care of RDHAPs patients with some degree of frequency. Percent of RDHAPs who Collaborate in Patient Care with Each Provider Type (n=74) Provider Type % RDHAPs Social Worker 52.7% Physician 51.4% Dental Specialist 45.9% Agency Manager 43.2% Registered Nurse 33.8% Health Aid 29.7% Physician Assistant 23.0% Nurse Practitioner 23.0% Nutritionist 12.2% Pharmacist 5.4% RDHAPs most frequently report interacting with social workers (59.2%) and agency managers (51%) in an administrative capacity. Pharmacists (8.2%) and nutritionists (6.1%) were the providers least frequently cited by RDHAP in administrative interactions. Health aids were cited by 20% of RDHAPs in an administrative capacity; which is on par with RDHAPs interactions with physicians and RNs. 23

Percent of RDHAPs who Interact in an Administrative Capacity with Each Provider Type (n=49) Provider Type % RDHAPs Social Worker 59.2% Agency Manager 51.0% Dental Specialist 26.5% Physician 24.5% Registered Nurse 22.4% Health Aid 20.4% Physician Assistant 14.3% Nurse Practitioner 14.3% Pharmacist 8.2% Nutritionist 6.1% Summary: RDHAPs collaborate with a wide variety of health care practitioners. When they refer patients, they most freqently refer to a patient s regular dentist, followed by referring to their dentist of record. A slim majority of APs (52%) find it easy to refer patients to a dentist who will provide treatment, and 70% find it easy to obtain a prescription to continue care beyond the 18 months allowed by regulation. RDHAPs most frequently refer patients to dental specialists, and they receive most referrals from social workers and agency managers. RDHAPs work collaboratively in patient care and in administrative capacities most frequently with social workers. 24

RDHAP Professional Development and Advancement The following section examines RDHAPs motivations for and experiences of practice as an RDHAP. These questions attempt to capture a deeper understanding of the RDHAPs perceptions of their work and the challenges they face as RDHAPs. For this reason, the analysis of responses is limited to only those RDHAPs who were working as RDHAP in California (n=118). RDHAP Motivation to Practice RDHAPs reported that they were most frquently motivated to pursue an RDHAP practice by their own personal satisfaction, Improving their ability to serve special needs patients, Desire for independence/autonomy, Passion to work with vulnerable populations, and Desire for greater flexibility in hours were all listed by more than 60% of respondents as motivations. Given the opportunity to specifiy other motivations to pursue RDHAP licensure, the desire to be a business owner was cited by two individuals. Other reasons given varied from a desire to work with the elderly to a desire expand access to care by dental hygienists. Motivation for choosing RDHAP Practice N Percent Personal satisfaction 99 83.9% Improve ability to serve special needs patients 85 72.0% Independence / autonomy 83 70.3% Passion to work with vulnerable populations 77 65.3% Increased job flexibility 75 63.6% Desire for more challenging position 58 49.2% Better hours / schedule 56 47.5% Improvement of professional standing 54 45.8% Community service 51 43.2% Better salary / benefits 39 33.1% Interact more with other health professionals 33 28.0% Greater job security 32 27.1% Other 6 5.1% Only job available 0 0.0% RDHAP Job Satisfaction and Barriers to Practice RDHAP Job Satisfaction: On average, respondents rated their job satisfacton with RDHAP practice as a 4.0 on a scale of 1-5, with 5 being the highest. The standard deviation among response was only.9 for job satisfaction, indicating that job satisfaction is quite high among practicing RDHAPs. On the same 1-5 scale, RDHAP rated their ease of establishing a practice as 3.5, with a standard deviation of 1.3. This indicates that RDHAPs experience of establishing a practice varied much more than does their job satisfaction. 25

Barriers to Dental Hygiene Practice: Respondents were asked to rate the barriers dental hygienists face in choosing to work as an RDHAP using a scale of 1-5, with 5 indicating the highest barrier and 1 indicating the lowest. RDHAPs rated Reimbursement/payment requirements (administrative hassle) and Poor egronomic conditions in non-traditional settings as the two highest barriers. The lowest barrier perceived by the RDHAP was Difficulty in obtaining RDHAP education. Barriers to Dental Hygienists (DH) Choosing RDHAP Practice (1=low barrier, 5=high barrier) (n=105) Avg. Rating (1-5) Standard Deviation Reimbursement/payment requirements (administrative hassle) 4.0 1.2 Poor ergonomic conditions in non-traditional settings 3.9 1.2 Scope of RDHAP practice 3.4 1.4 Lack of awareness of employment opportunities 3.2 1.4 Complex needs of RDHAP patients 3.2 1.4 DH lack of interest 3.1 1.4 Lower pay for DH in non-traditional settings 3.1 1.4 Poor environment or location of non-traditional settings 2.9 1.3 Inability to practice high quality care in non-traditional setting 2.6 1.3 Difficulty in obtaining RDHAP education 2.1 1.2 Issues Impacting Daily RDHAP Practice: RDHAPs were asked to rate the degree to which certain issues impact their decisions and activities in the daily operations of their RDHAP practice. The scale used was 1-6, with 1 being not at all and 6 being to a great extent. Two of the three highest impact issues were a Lack of public awareness about about the RDHAP profession and Lack of awareness about RDHAP profession in health organizations. The two lowest impact issues for RDHAP in the operations of their daily practice were State regulators oversight of your practice and Competition from RDHAPs. 26

Impact on RDHAP s Practice Decisions and Activities (1=not at all, 6 = great extent) (n=105) Avg. Rating (1-6) Standard Deviation Lack of public awareness about RDHAP profession 4.7 1.4 Changing regulations within Denti-cal 4.5 1.7 Lack of staff awareness about RDHAP profession in health orgs. 4.4 1.6 State laws or regulations on RDHAP scope of practice 4.1 1.7 Low Denti-cal reimbursement levels 4.1 1.9 Hostility from local dentists or dental societies 4.1 1.8 Difficulty getting payments from 3rd-party payers 3.9 1.8 State laws or regulations on RDHAP work sites (e.g., Title 22) 3.9 1.8 Policies of local partner institutions, such as nursing homes, schools, etc. 3.8 1.6 Knowledge of other RDHAP's businesses 3.6 1.6 Competition from dentists 3.4 1.9 Information from state dental hygiene assoc. 3.2 1.6 Difficulty working with local institutions and agencies 2.9 1.5 Ergonomic issues 2.8 1.6 Availability of jobs in local health care organizations 2.7 1.5 Available technology for RDHAP practice 2.7 1.4 RDHAP listserve and/or RDHAP meetings for sharing information 2.7 1.5 Clinical needs of RDHAP patient population 2.6 1.5 Malpractice insurance cost increases 2.4 1.3 Difficulties staffing an RDHAP practice (HR, hiring, etc.) 2.1 1.4 State regulators oversight of your practice 2.0 1.3 Competition from RDHAPs 1.9 1.4 Summary: While satisfaction with their work as RDHAPs is generally high, respondents ease in establishing their RDHAP practice is more varied. RDHAPs perceive reimbusement issues and ergonomic conditions as significant barriers to RDHAP practice. Neither the educational requirements for RDHAP licensure nor their ability to provide high quality care in alternative settings were viewed as barriers to pursuing RDHAP practice. A general lack of awareness among health care providers and the general public of RDHAP practice along with changing regulation within Denti-Cal have the greatest impact on RDHAPs daily operations. 27

STUDY LIMITATIONS This study has a number of limitations which should be noted. The response rate was 72% and respondents closely matched the sampled groups providing good representation from providers in the field. However, given the small overall pool of licensed RDHAPs (n=244) and wide variation in provider activity broad generalizations beyond this study population are not possible. REFERENCES California Department of Finance (2010). Data Table E-3 Race/Ethnic Population Estimates. California Health Interview Survey (CHIS) (2009). CHIS 2007 Adult, Adolescent, and Child Public Use Files. [computer file], UCLA Center for Health Policy Research. Gehshan, S., Takach, S., Hanlon, C., Cantrell, C. (2009) "Help Wanted: A Policy Maker's Guide to New Dental Providers." http://www.pewcenteronthestates.org/uploadedfiles/dental_report_help_wanted.pdf Mertz, E. (2007). California Survey of Dental Hygienists, 2005-2006: A Workforce Profile. San Francisco, University of California San Francisco, Center for the Health Professions. http://futurehealth.ucsf.edu/content/29/2007_03_californina_survey_of_dental_hygienists.pdf Mertz, E. (2008) "Registered Dental Hygienists in Alternative Practice: Increasing Access to Dental Care in California." http://futurehealth.ucsf.edu/content/29/2008-05_registered_dental_hygienists_in_alternative_practice_increasing_access_to_dental_care_in_ California.pdf Mertz, E., Bates, T. (2008) "Registered Dental Hygienists in California: Regional Labor Market Chart Book." http://futurehealth.ucsf.edu/content/29/2008-11_registered_dental_hygienists_in_california_regional_labor_market_chart_book.pdf Mertz, E. and P. Glassman (2011). "Alternative practice dental hygiene in California: past, present, and future." Journal of the California Dental Association 39(1): 37-46. Mertz, E. and W. E. Mouradian (2009). "Addressing children's oral health in the new millennium: trends in the dental workforce." Academic pediatrics 9(6): 433-439. Mertz, E. A. and L. Finocchio (2010). "Improving oral healthcare delivery systems through workforce innovations: an introduction." Journal of public health dentistry 70 Suppl 1: S1-5. 28