Partnership with School Board for Full-service School-based Dental Program in Pasco County

State: FL Type: Neither Year: 2015

Providing Access to Dental Care with a School-based Full-service Dental Program in Dade City, FL The school-based Full-service dental program was developed to increase access to dental care for underserved pediatric Medicaid clients and uninsured children in Dade City, Florida. Unique in its scope of services that go beyond screenings, cleanings and sealants, this program was designed to serve a priority population in the rural county seat. According to 2010 U.S. Census data, Dade City experienced an approximate 5% population growth to bring its population to about 6,500 residents. Notably, the estimated 2011 median household income in Dade City in was $24,999 compared with the state median of $44,299. The Florida Department of Health in Pasco County (DOH-Pasco) serves the county’s population of more than 470,000 at five sites including a service location in Dade City. Barriers to pediatric dental care in Dade City include a scarcity of dental providers that accept Medicaid, transportation issues, lack of parental understanding of the importance of oral health care, and parental compliance with appointments. The overarching goal of our initiative is to provide dental care to  underserved children. A key objective was to serve a minimum of ten students per day, three days per week with one dental chair/unit. The DOH-Pasco partnered with the District School Board of Pasco County and the Rodney B. Cox (Cox) Elementary School to revive a dental facility built at Cox Elementary School in 1994 through a grant. Since 1994, this school dental facility had been used sporadically and in a limited capacity through arrangements with volunteer dentists. There was no strategic plan for the program nor long-term sustainability goals. The dental facility was underutilized and did not fulfill the funding grant’s intent. In 2011, the DOH-Pasco initiated the program by providing a dentist, dental assistant and a front office clerk for three days per week to serve the dental care needs of students at Cox Elementary and the surrounding schools. DOH-Pasco assumed financial responsibility to maintain the dental facility and provide supplies needed to operate the dental clinic. The dental clinic consists of two dental treatment rooms, sterilization room and a dental office. With referrals from school nurses in the Pasco County School District from February 2011 to present, the dental team housed at the Cox Elementary Dental Clinic has treated more than 1,200 patients, from 22 surrounding schools. The age of the patients range from 1- 20 years old. Treatment provided at the Cox Elementary Dental Clinic included dental cleanings, dental exams, x-rays, sealants, fillings and extractions. Overview This full-service dental school-based program has impacted the oral health of the children in Dade City. Our objective was to provide dental treatment for approximately ten children per day with the one dental chair/unit working at the school three school days per week. We have meet and sustained these numbers since the start of the program in February 2011.  The clinic now has two dental operatories in service  at the school four days per week. The continued success is due to the collaborative efforts with the school nurses and their referrals in the surrounding schools. This joint effort serves youth who are less likely to receive private dental care, such as children from low-income families. With early dental preventive care, more than half of a child’s tooth decay can be prevented thus saving money on future treatment costs along with promoting sound oral health for a lifetime. This program has afforded dental care and education to families in need in Dade City. The collaboration between the DOH-Pasco and District School Board of Pasco County has resulted in a sustainable plan to address the lack of access to dental care in Dade City school-aged children. The onsite facility eliminates the barriers to care and allows for students to receive dental treatment while minimizing missed class time. Our website is accessible to locate the dental clinic in Dade City, FL.  
The DOH-Pasco provides public health services to the approximately 470,000 residents within its 744 square mile jurisdiction on the Gulf of Mexico in the Tampa Bay area. DOH-Pasco has five service sites located in or near the larger municipalities and population centers. Although no longer considered a rural county, areas in eastern Pasco County are home to agricultural and farming industries. About 17% of Pasco’s population is school-aged (5-18 years of age). DOH-Pasco and community partners identified access to health care, and oral health care in particular, as a strategic priority of the community health improvement plan. The oral health care access priority aligns with several state-level goals as well as objectives in DOH-Pasco’s strategic plan. Access to preventive oral health services in rural Pasco County has been a long-standing, complex public health challenge. It is well established that those with limited access to dental treatment have higher rates of oral diseases and that lack of access to oral health services can be associated with factors such as income, education level, race and ethnicity. The priority population for this school-based dental program is school-aged children at Cox Elementary School in Dade City. Cox Elementary has a student census of about 500 with 98% qualified for the free or reduced-cost lunch program. The diverse race and ethnicity of the student population is made of up 66% Hispanics, 24% Blacks, 7% Whites, 2% multi-racial, and 1% Asians.   Previous attempts to provide school-based dental care by the school were unsatisfactory because of their limitations and unsustainability. Prior to the DOH-Pasco and school collaboration, there were efforts by Cox Elementary to seek a local volunteer dentist to provide emergency dental care for the children within the community at their school. However, this effort had limited continuity of care and follow-up treatment for the children. Due to the lack of funding and difficulty recruiting a volunteer dentist to provide these services the program was discontinued, thus leaving the children without dental care and a dental home. The current program is guided by a plan, goals and objectives developed cooperatively by DOH-Pasco and the District School Board of Pasco. In 2011 both organizations became party to a Memorandum of Understanding for long-term goals to serve the oral health needs of this community’s children. These goals included DOH-Pasco assuming financial responsibility to maintain the dental facility and provide staff and supplies needed to operate the dental clinic. The cooperative relationship with the District School Board of Pasco County made available the existing dental facility that had been built at Cox Elementary in 1994 under a grant that initially was to implement this school-based dental program. DOH-Pasco provides a dentist, dental assistant, and office clerk at the school so that students receive dental treatment and oral health education with shorter student time away from the classroom. In addition, the DOH-Pasco dental program works with referrals from area school nurses within the Pasco County School District which allows for surrounding schools to participate with the school-based dental program at Cox Elementary. DOH-Pasco’s school-based full-service dental program is novel in its scope and innovative in approach to assuring access. Most school-based dental programs address preventive dental concerns or needs such as sealants and dental cleanings. This dental program is a full-service dental school-based program that provides routine fillings, dental exams, x-rays, sealants, dental cleanings, fluoride treatments and extractions for children who are less likely to receive private dental care. The Centers for Disease Control and Prevention (CDC) projects that if children at high risk participated in school programs, over half of their tooth decay would be prevented and money would be saved on their treatment costs. The DOH-Pasco school-based program addresses CDC’s concerns by providing comprehensive dental care to school-aged children regardless of their ability to pay. In addition, the DOH-Pasco dental program provides instruction to emphasize the importance of proper oral hygiene which promotes a healthier learning environment for all children in the school. Strong proof of effectiveness in preventing tooth decay has prompted the Community Preventive Services Task Force to recommend school-based dental sealant programs. The DOH-Pasco school-based program has built on this evidence-based approach to include comprehensive dental services.  
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The Full-service school-based dental program in Dade City came to fruition under the shared leadership of the District School of Board of Pasco superintendent of schools, district student services director, school principals and nurses along with the DOH Pasco health officer, dentists and dental program manager. The gap in oral health services and impact on health outcomes was confirmed as part of a comprehensive community health assessment. The need for oral health services rose to the level of a strategic priority in the community health improvement plan. Combing through assessment findings while in the strategizing phase of plan development, the identification of geographic sites with multiple health challenges emerged. From this isolation of Dade City as a pocket of need, further prioritizing and planning pointed to the dormant asset at Cox Elementary. School and public health partners developed the plan that was formalized as a memorandum of understanding between the District School Board of Pasco County and DOH-Pasco. While crafting the memorandum of understanding related processes and materials were created including parental informational materials, permission forms, school procedures and protocols for information security and client safety. In addition to dental service goals, financial goals were drafted. These goals reflected the assumption of maintenance, operating, and staffing expenses by DOH-Pasco, efforts to seek reimbursement through Medicaid, Kid Care and other insurance plans, and fiscal management towards self-sustainability of the dental clinic. Other infrastructure goals focus on implementation of electronic dental records at the school-based clinic and expansion to include outreach and mobile dental unit to serve other Title I schools in the county.   The start-up costs for this program were approximately $8,000. The DOH-Pasco provided maintenance on the dental equipment to include the dental chair, autoclave, and x-ray developer. Also purchased were computer, printer, copier, and dental supplies to include instruments, hand pieces, ultrasonic scaler, x-ray unit, and disposable materials to meet the Department of Health rules and regulations for operating a dental facility.   With the goal of providing comprehensive dental services to students at Cox Elementary and surrounding schools in Dade City, a key objective was set: serving a minimum of ten students per day, three days per week with one dental chair/unit. To accomplish both the goal and objective, the implementation strategy commenced with a Memorandum of Understanding (described above), identification of a dentist and staff, and securing of equipment and supplies. Using an existing dental operatory greatly reduced start-up time and expense. Existing cooperative and collaborative relationships between DOH-Pasco and the school staff on other health –related projects eased the way towards implementing the plan. Working with referrals from school nurses from February 2011 to present, the dental team housed at the Cox Elementary Dental Clinic has treated more 1,200 patients, from 22 surrounding schools. Routinely performed services include dental exams, amalgam fillings, composite fillings, extractions, x-rays, sealants, dental cleanings and fluoride treatments. The Cox Dental Clinic has grown from one dental operatory working three days a week to now having two dental operatory’s  working four days a week 10 hours days, and established electronic health records for patient care.  This increase has been accomplished in four years providing dental services for a Full-service school based clinic.   
The scarcity of dental providers in the Dade City area made Cox Elementary School an ideal site for a Full-service school- based dental program. The priority population for our full service dental program is children who are less likely to receive private dental care, such as children from low-income families. With early oral health care, over half of the tooth decay a child would sustain could be prevented. This not only saves money on treatment costs but improves related health and quality of life outcomes. The program’s key performance objective was to provide dental treatment for approximately ten to fifteen children per day with the one dental chair/unit working at the school three school days per week. This objective has been achieved and surpassed with the recent addition of a dental operatory chair/unit and working four days a week and establishing electronic health records since the program initiation in February 2011. Related benefits and impacts have accrued. For example, many parents elect to have their children treated at the Cox Dental Clinic because of the facility’s convenient location. The comprehensive services provided by the dentist, dental assistant, and office clerk at the school allows students to receive dental treatment and education with shorter time away from the classroom than a traditional dental appointment at a private clinic. Coordination with the school nurses from surrounding schools ensures each child will complete the recommended treatment and promotes a healthier learning environment. The full-service school-based treatment facility at Cox Elementary School is a model for other rural communities and dental programs since this is the only one in the State of Florida.  
Valuable lessons were learned from previous attempts to implement a school-based dental program. Among those are the importance of shared goals among the collaborating partners. The partners remain invested in the program’s success by each having organizational goals and objectives in addition to the shared community health improvement plan goal. The criticality of having a formal plan was a detriment to prior efforts and a strength of today’s program. As mentioned, the DOH-Pasco and District School Board of Pasco County have been trusted partners on numerous projects for many years; however, this school-based program was developed as a business venture in addition to its public health focus. To maintain a quality, effective and sustainable program, the partners at a minimum conduct an annual joint review. Both the District School Board of Pasco County and DOH-Pasco employ their own internal monitoring for performance and quality. Fiscal management and budget impacts are monitored monthly by DOH-Pasco. Financial goals provide targets for maintaining solvency while driving for expansion when fiscally feasible. Sustainability strategies include community involvement in institutionalizing dental care as a school service, employing professional staff rather than depending on volunteers, fostering the creation of a dental home for the student and the student’s family to embed and root the service in the community, and seeking funding and program partners.  
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