Hawaii is composed of seven populated islands located in four major counties. The Hawaii Department of Health (DOH) is the only public health agency in the state. A long-standing DOH dental health program focused on school children and led by a state dental director was eliminated in 2009 because of budget restrictions due to the state and national recession. DOH continues to operate several direct service dental clinics located in Oahu under the Division of Developmental Disabilities (DDD), since this is the primary population served. In 2012 oral health planning and surveillance responsibilities were assigned to the Family Health Services Division (FHSD), the DOH maternal and child health (MCH) program. FHSD includes three branches: WIC, Maternal and Child Health and Children with Special Health Needs and also houses the DOH Office of Primary Care and Rural Health. FHSD has no dental health professionals on staff, thus works closely with the DDD that employs several dentists and dental assistants in its dental clinics. The former DDD Chief was also a dentist but has since retired. The Hawaiian Islands Oral Health Task Force was established in 2002 to help implement the provisions of the 2002 state oral health plan. Activities and structure of the group languished since 2006, but DOH has worked with the Hawaii Primary Care Association in the past two years to revitalize the group.
While Hawaii has many dedicated oral health stakeholders and community-based programs, a major challenge is the lack of oral health infrastructure to develop a coordinated system of care. Unlike most states, Hawaii has no local health departments, thus DOH is key in providing statewide leadership for critical public health surveillance, evaluation, planning and prevention functions. Given the state’s unique diversity in ethnicity, language and cultural practices, many best practices may not translate to Hawaii. With no dental school in Hawaii, DOH plays an important role to promote evidence-based oral health practices in both public and private settings by supporting workforce training, policy guidance, and research. The state also lacks a current strategic oral health plan; the last plan is nearly 10 years old. Hawaii has never provided complete data to the NOHSS because it has been unable to generate surveillance data for the indicators, and no data had been collected since 2009. [Note: since receiving the CDC grant award, Hawaii has been reporting all available data to NOHSS and completing the annual state synopsis.]
DOH assembled a team and applied for and was awarded one of the DP13-1307 Component 1 grants from the Centers for Disease Control and Prevention in 2013. The CDC State Oral Disease Prevention grant allows the state to establish and hire a Dental Director and some part-time support staff. Although Hawaii has experienced challenges trying to fill the Dental Director position, DOH staff decided to begin utilizing the grant funds to start building surveillance capacity, conduct an environmental scan, promote partnerships, and initiate other oral health activities to lay the foundation for state planning. Salary savings were utilized to contract services while the dental positions were being established. A diverse team of DOH staff was assembled to plan and manage the activities. None of the staff were dental professionals. Content expertise was largely provided by ASTDD. DOH also obtained guidance from the CDC program officers.
The CDC oral health grant requires DOH work to build partnerships through all project work. Partnerships have allowed DOH to leverage limited resources to achieve public health functions. The third grade oral health survey serves as a perfect example. Partnerships for this project include:
- The Department of Education (DOE) Superintendent, Central and District office staff, principals, and school health aides have been instrumental in supporting the project.
- With limited staffing, DOH contracted with the Hawaii Primary Care Association to implement the survey.
- Additional support has been provided from within DOH including Public Health Nursing, the Office of Program, Planning and Policy Development, all three District Health Offices, Immunization Branch, and the Medical Services Corps.
- The Association of State and Territorial Dental Directors (ASTDD) Data and Surveillance Coordinator is providing technical assistance for the planning, training of screeners, and data analysis for the project.
- Funding for the project has come from the DOH CDC oral health grant, a grant from the Hawaii Dental Service Foundation (Delta Dental affiliate), and two federal DOH grants (HRSA State Systems Development Initiative and CDC Preventive Health and Health Services Block grant).
- Screeners for the project have been recruited from the membership of the Hawaii Dental Association, the Hawaii Dental Hygienist Association, the Federally Qualified Health Centers, as well as the Lutheran Medical Center Pediatric Dental Residency Program.
- Community volunteers are contributing valuable support. An example includes the use of the DOH Planner’s daughter’s Girl Scout troop that assembled 5,000 dental goodie bags. The evening effort resulted in the scouts receiving a service badge.
Another example of a DOH partnership is the development in February 2015 of a grant application with the University of Hawaii School of Nursing and Dental Hygiene for a federal Maternal and Child Health Bureau Perinatal Oral Health grant to develop best practices and measures to improve oral health services to pregnant women and infants in the state. Although the grant was not submitted, the project proposal is being submitted to the Hawaii Dental Service Foundation for funding.
The partnerships developed to date have helped DOH move oral health activities forward and will ensure any future statewide planning/consensus effort will involve broad representation and participation by diverse stakeholders.
Oral health progress as a result of DOH leadership and partnerships during the first two years of the grant include:
- Completion of an Oral Health Surveillance Report of existing data including self-reported survey data; hospital emergency room data; Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) data; and licensure data for dental professionals. The report will be posted to the DOH website and a Key Findings summary report is scheduled for publication in August 2015.
- In October 2014, the DOH hosted an oral health data workshop facilitated by the Iowa Dental Director, Bob Russell, DDS. Thirty-five oral health stakeholders participated to identify state oral health data needs. Members from the workshop now meet quarterly to follow up on recommendations developed from the workshop. The data advisory group members have provided critical input on draft data publications.
- In early 2015 the DOH is conducting a 3rd grade Basic Screening Survey to collect data on the oral health status of children. The representative sample involves 64 public and charter schools throughout the state on all six islands. The survey data will provide county and state-level estimates on treated and untreated tooth decay as well as the prevalence of dental sealants.
- A draft Oral Health Data Surveillance Plan has been completed with ASTDD’s assistance and will be shared with stakeholders for further review and input. Evaluation plans were also completed with TA from ASTDD.
- DOH contracted with the Children’s Dental Health Project (CDHP) to initiate a policy review of oral health legislation in 2015. In addition, DOH has contracted a local dental professional to complete a profile of state oral health resources that includes workforce data, safety net services, and other major community and state-level programs. The report will also include an analysis of the information to identify gaps, areas of duplication and collaboration.
- The CDHP conducts a policy consensus process recommended by CDC to convene diverse stakeholders to review data, policy and resource information to develop public policy recommendations. Hawaii DOH is interested in utilizing the process once data surveillance, policy and program profiles are completed.
- DOH initiated planning for a school-based oral health prevention program that would include sealant application as part of a project supported by the Aspen Institute for Excellence in Public Health Law. Hawaii was selected to participate in the program in 2013 and chose oral health as its focus. A team of key state policymakers is participating in the project including legislators, the Governor’s Office, the Attorney General as well as the Department of Health. DOH is proposing to partner with two FQHCs to pilot a school dental sealant program to take advantage of enhanced reimbursements to sustain/fund an ongoing program. A funding proposal for the pilot was submitted by DOH to the Hawaii Dental Service Foundation and awarded in April 2015. The Foundation expressed strong interest in the proposal since other state Delta Dental foundation affiliates fund school dental sealant programs with great success.
- Partnering with the American Academy of Pediatrics-Hawaii Chapter to conduct fluoride varnish training for pediatric and family practice providers statewide. The trainings were timed with the release of the new AAP national guidelines promoting FV application and the recent state Medicaid policy decision to reimbursement FV application by medical providers.
- Strong public health leadership is critical to guide planning and assure progress with the CDC Oral Health Disease Prevention grant. The acting Dental Director, a non-dental professional, was trained in public health administration and served as the former manager of the state chronic disease program, thus she was extremely knowledgeable/experienced regarding the public health approach to program development and problem solving.
- ASTDD content expertise, technical assistance, orientation was critical to guiding planning, implementation, and achieving CDC grant benchmarks and requirements.
- Locating the oral health program in the MCH agency, with a culture of working in collaboration and partnership, helped facilitate:
- teamwork among a diverse group of staff,
- working with internal/external partners and
- leveraging resources.
- The MCH agency also provided access to extensive resources including MCH epidemiology staff, Office of Primary Care and Rural Health, as well as a number of federal HRSA grant resources.