Our service delivery model for specialty oral surgery care for low-income uninsured and under-insured dental patients is an adaptation of the extremely successful Project Access Northwest medical model that already operates at Swedish Community Specialty Clinic (SCSC). Patients with complex acute oral surgery needs are referred from their safety net clinic provider to Swedish Community Specialty Clinic and Project Access Northwest.
The Project Access Northwest referral and case management system is effective as measured by an impressive 4.3% “no show” rate (the “no show” rate reported for Medicaid/Uninsured patients has been reported to be approximately 30% and approximately 15% for commercially insured patients). Since opening its doors in September 2011 and providing care two days per week, this year the Clinic achieved its goal of being open five days per week (236 days in the 12 months of this reporting period, a 57% increase over 2012-2013). The Clinic is primarily staffed by General Practice Residents (GPR) and their supervising dentists as well as volunteer dentists and oral surgeons.
By December 2014, there were 15,590 teeth extracted. The specialty oral surgery care delivered by the Clinic also includes bone re-contouring surgery and biopsies all with a total donated care value of $4,426,018. The Clinic costs for 2013-2014 are $475,900 with Swedish Medical Center, the Pacific Hospital Preservation & Development Authority and the Seattle-King County Dental Foundation covering the cost of 3.0 FTE paid personnel (two dental assistants, partial FTE dentist, and partial FTE dental director), overhead and supplies.
Prior to the creation of the SCSC, we instituted a ‘golden ticket’ program with the Emergency Department (ED) physicians at Swedish Medical Center to try to assist them in effectively treating the growing number of dental patients. When a patient with a non- traumatic dental condition presents at the ED (e.g., there is a non-life threatening abscess/infection or there is pain without visible infection), the patient is given a referral sheet (the golden ticket) from the ED physician. The ‘golden ticket’ directs them to the closest FQHC where they are prioritized in the next morning’s walk-in emergency dental clinic. This program has no cost beyond volunteer dentist time educating the ED physicians on the process and networking with the closest FQHC. HIPPA restrictions and limited ED staff time along with inadequate resources at the FQHC, has made the collection of data on the number of patients who have actually followed through and received care at the FQHC unattainable. In the first 18 months of the program, of the 759 patients who went to the ED for dental, 218 or almost 30% were given a ‘golden ticket’ and did not receive treatment at the ED.
- Performing a community needs assessment is critical to the success of such a program. The Dental Society learned from the community and its stakeholders. We did not have the time or the resources to do a scientifically based assessment. Rather, we gathered all the County CHC dental directors and their administrative leads in a room along with our partners and made a list of what was needed and then prioritized the needs. This earned the Dental Society additional trust and was critical in the formation of an effective coalition with a shared vision.
- The dental safety net clinics are not referring their routine cases. A majority of the extractions being referred to the SCSC are quite challenging. Similarly, they are referring complex third molar extractions and pathology cases to the SCSC.
- Patients often need more than one appointment to complete the required care. Our initial assumption was that the patient needs would typically be met in a single appointment. Given the poor oral health of many of the referred patients, multiple appointments are often needed to complete the treatment plan. Additionally, a block of time needed to be included into the Clinic’s regular schedule to follow-up with patients who were experiencing anxiety about their healing.
- Many patients want to be “knocked out” for their extractions. Moderate sedation, deep sedation and general anesthesia cannot be accommodated in this model of acute care delivery. SCSC does offer minimal sedation with oral agents and nitrous oxide sedation. Some patients are willing to proceed with minimal sedation, while others refuse.
- An “on-site” dental director (the part-time position) is essential. The director monitors the skill and comfort levels of the volunteers, and steps in should volunteers need assistance with complex procedures or if there are no volunteers available.
- There have been barriers for patients needing initial consults in the FQHC dental safety net clinics. Some patients find their sliding scale fee to be an obstacle. We have been working with the dental safety net clinic dental directors and referral coordinators to resolve such barriers.
- Many of the referred patients have such poor oral health that they require full mouth extractions. Because there is limited funding for dentures, some patients have been reluctant to have the recommended number of teeth extracted. In recognition of this patient concern, the Seattle-King County Dental Society has received funding to include the University of Washington School of Dentistry in the partnership. Following a full mouth extraction at Swedish Community Specialty Clinic’s oral surgery clinic, the patient would be referred to the School of Dentistry’s pre-doctoral removable prosthodontics clinic for denture fabrication. This program began in the fall of 2014 and has been recently funded for a second year.
- The dental assistant position was originally supervised by Project Access Northwest and had some caseworker duties. It is our experience that the skill sets of a caseworker and of a dental assistant cannot be successfully combined and need to be two different positions.
- Finding the optimal balance of patients for a caseworker to manage each quarter is important to the program’s success, especially as measured by the engagement of the volunteers. In this model, a caseworker who is dedicated exclusively to dental patients can successfully manage 450 patients per year (approximately 150 referrals per month from the dental safety net clinics).
Golden Ticket Program
- This program is challenged by working with ED physicians. As these individuals are extremely busy while working, it is difficult to get their attention in order to explain the program to them. Additionally, given the tight time constraints under which they work, their reporting of patient outcomes was often not complete.
- Due to lack of funding for statistical analysis, it has not been possible—beyond anecdotal reports by the ED physicians—to measure the true effectiveness of this program.
- It is important to note that, of the 759 patients during the reporting time, only 14 of them were in enough dental distress to be admitted to the hospital—a determination made by the GPR residents on call.
- Swedish Hospital has been unable to measure quantitatively how this program impacted ED utilization for dental patients.
Jennifer L. Freimund, Executive Director, Seattle-King County Dental Society and Foundation, 1111 Harvard Avenue, Seattle, WA, 98122, Telephone: 206-448-6615, Fax: 206-443-9308, Email: Jennifer@skcds.com
Dr. Noah Letwin, Dental Director, Swedish Community Specialty Clinic, 801 Broadway, Heath Building, Suite 901, Seattle, WA, 98122, Telephone: 206-524-1600, Email: Noah.Letwin@swedish.org