Social drivers of health, including access to nutritious foods, transportation, and access to health care, continue to exacerbate disparities in oral health and overall health, particularly for Medicaid beneficiaries.
Emphasizing increased access to care and prevention through early oral health interventions can reduce the development of severe dental disease that can lead to costly and invasive care, such as emergency department visits, fillings, and tooth extractions. Increasing opportunities to access minimally invasive care (MIC), which is less painful and expensive than traditional dental care and can be delivered in community settings, is one strategy some states are adopting to improve oral health outcomes and reduce disparities for Medicaid beneficiaries. Oral health transformation efforts across states, such as Rhode Island, have included efforts to expand the role of non-dentist providers and opportunities for MIC in community settings.
What Is Minimally Invasive Care (MIC)?
“Minimally invasive care (MIC) in dentistry is focused on preventing and healing tooth decay without removing any tooth structures. MIC includes prevention, counseling, and painless treatments, such as fluorides, antimicrobials, diagnostic solutions, and therapeutic fillings and sealants that are brushed onto teeth.”
Oral Health Transformation in Rhode Island
Following the COVID-19 pandemic, challenges reported by providers and patients prompted Rhode Island to design an interagency approach to transform oral health for Medicaid beneficiaries using strategies to expand the dental workforce and access to dental services in communities.
Oral health transformation in Rhode Island is a multipronged approach to improve well-being and systemic health of Medicaid beneficiaries by strengthening the dental health workforce and expanding access to preventive oral health care through five key strategies (see Figure 1).
Key initiatives of this approach include increasing Medicaid reimbursement rates within home- and community-based services, promoting provider participation, leveraging and strengthening the public health dental hygienist workforce to increase access to preventive care, expanding access to routine oral health care to prevent severe disease by expanding to alternate service locations (including home- and community-based settings), and improving outcomes from oral health emergencies through interdisciplinary provider collaboration.
State oral health officials also meet regularly with an interagency team to find the best ways to meet the oral health needs across different populations.
Public Health Dental Hygienists
One approach that Rhode Island is taking to strengthen opportunities for prevention and early interventions for Medicaid beneficiaries is by training and deploying public health dental hygienists (PHDH) to provide oral health care and treatments in community-based settings. Public health dental hygienists can provide oral health services to Medicaid beneficiaries in the community, such as schools, homes, and assisted living centers, eliminating the need for individuals to find and see a dentist first.
What Is a Public Health Dental Hygienist?
“A public health dental hygienist (PHDH) is a practicing registered dental hygienist who is certified to perform dental hygiene procedures without immediate or direct supervision of a dentist. PHDHs are certified to perform procedures in public health settings [that include] schools, long-term care facilities, clinics, mobile dental health vans, and others.”
Source: Community College of Rhode Island
Rhode Island’s PHDHs can bill Medicaid for preventive services, including MIC interventions such as administration of a caries assessment, application of silver diamide fluoride, and scaling. The state has also made investments to pay for PHDH training at the Community College of Rhode Island and runs a monthly learning collaborative for PHDHs to connect professionally and learn about work happening in other states.
Community- and Home-Based Oral Health Care Pilot Grants
In addition to investing in the PHDH workforce, Rhode Island’s Community and Home-Based Oral Healthcare Pilot provides funding via Home and Community-Based Services Enhanced Federal Medical Assistance for dental services to be administered by Medicaid providers in community settings. The state is currently assigning contracts to pilot grantees: home health agencies, public health dental hygienists, and dentists. The pilot infrastructure is designed for home health agencies to provide initial mouth assessments and arrange preventive care with a PHDH for those without a dental home.
Why Provide Oral Health Care and Training in Home Health Settings?
Due to dental care shortages caused by the COVID-19 pandemic, home health agencies became a viable option to connect patients, especially older adults receiving care outside long-term care settings, to dental services. To prepare certified nursing assistants working in home health agencies to provide these services, Rhode Island created a self-paced online training in mouth care and oral assessment. A version for Spanish speakers is in development.
For more complicated oral health needs, PHDHs can refer patients to a dentist. In addition to receiving Medicaid reimbursement for billable expenses, grantees receive incentive payments for a variety of tasks, including making referrals, completing trainings, and submitting data, as part of a value-based strategy to increase the number of Medicaid enrollees with a dental home and decrease the utilization of emergency departments for oral pain and infections.
Strengthening linkages between dental providers and communities
While early in the stages of implementing new strategies to improve access to oral health care, Rhode Island has introduced infrastructure to collect data and measure improvements to understand the impact of these programs. By not only investing in the workforce but also developing a sustainable workflow that increases collaboration between public health, community providers, and dentists, the state has created an accessible pathway linking community members to dental providers. Future initiatives that the interagency group would like to discuss include an emergency department diversion program and exploration of opportunities to support dental care for those experiencing substance use disorder and those who are in recovery.
Conclusion
Oral health is part of overall health. Increasing preventive services through MIC interventions and home- and community-based services can promote health and help address cost and comorbidities associated with poor oral health. Amidst broader health care workforce shortages, of which the dental field is no exception, leveraging minimally invasive treatment options in community-based settings is one strategy other states can adopt to increase access to oral health care for Medicaid beneficiaries. Working with community-based organizations and health care settings that serve Medicaid populations can improve opportunities for prevention and screening, including connecting patients with additional social interventions that can improve health.
Acknowledgement
The National Academy for State Health Policy (NASHP), with support from the CareQuest Institute for Oral Health, regularly convenes state officials to discuss strategies to address health disparities and implement best practices in oral health policies through minimally invasive care. NASHP staff would like to thank state officials from Rhode Island for presenting on oral health transformation at a recent workgroup convening and for their input on this blog post. Please reach out to Megan D’Alessandro (mdalessandro@nashp.org) with any questions or inquiries about joining the State Oral Health Policy Workgroup.
