Jefferson County Public Health - Integrating Cavity Prevention with WIC Nutrition Services

1. JEFFERSON COUNTY PUBLIC HEALTH
Integrating Cavity Prevention with WIC Nutrition Services
Replication
Manual

2. INTEGRATING CAVITY PREVENTION WITH WIC NUTRITION SERVICES
Replication Manual
Prepared by:
Melissa Broudy, RN, BSN, BA
Under supervision of:
Susan Moyer, RN, MSN, CNSPH
Jefferson County Public Health
1801 19th Street
Golden, CO 80401
Phone 303.271.5700 • Fax 303.271.5702
With special thanks to:
Cavity Free at Three Team Members
Linda Reiner, MPH
Diane Brunsen, RDH, MPH
Dr. Denis Lewis, DDS
Made possible by grant award from:
Cavity Free at Three,
a three-year, statewide effort to prevent oral disease in young children. The effort aims to engage dentists, physicians, nurses, dental
hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant
women, infants and toddlers.
The project is jointly funded by: Caring for Colorado Foundation, The Colorado Health Foundation, The Colorado Trust, Delta
Dental of Colorado Foundation, Kaiser Permanente and Rose Community Foundation and implemented in partnership with the
University of Colorado Denver School of Medicine, Department of Family Medicine and the University of Colorado Denver
School of Dental Medicine.

3. Table of Contents
Overview ................................................................................... 1
Why cavity prevention is good public health ............................. 1
Cavity Free at Three ....................................................................... 1
Prevalence in Colorado................................................................... 1
Jefferson County Public Health WIC Clinics ................................... 2
Public Health Cost of Dental Caries ................................................ 2
Removing client barriers to preventive care .............................. 3
Maslow’s Hierarchy of Needs.......................................................... 3
Time Costs...................................................................................... 3
Financial Costs ............................................................................... 4
Travel Costs.................................................................................... 4
Delivering a public health cavity prevention model ................... 4
Oral Health Promotion Meets Existing Public Health Infrastructure 4
Staff and Contractor Training in the Infant Oral Health Model......... 5
Developing Local Referral Resources............................................. 5
Independent dental hygienists provide financial sustainability .. 6
Colorado Practice Law for Registered Dental Hygienists................ 6
Recruiting independent RDHs......................................................... 7
Establishing a No-Cost Contract with Incentives Sufficient to Attract
and Retain RDHs ............................................................................ 7
Immunization Requirements ........................................................... 7
Work Space .................................................................................... 8
Supplies .......................................................................................... 8
Flexible RDH Schedules ................................................................. 9
Managing Client Flow...................................................................... 9
Orienting RDHs ............................................................................. 10
Orienting WIC Staff ....................................................................... 10
Pathways for Ongoing Communication ......................................... 10

4. Overview
Dental disease is the number one chronic disease of children in
America, yet, it is a preventable disease.
J efferson County Public Health (JCPH) has teamed up with the Cavity Free at Three
Technical Assistance Team, WIC staff, and independent Registered Dental
Hygienists (RDHs) to prevent cavities in pregnant women and children ages 0-5.
JCPH has contracted with three independent RDHs to deliver the Cavity Free at
Three infant oral health model to WIC clients as they attend appointments. This
model’s success is founded in (1) removing client barriers to care, (2) delivering a
proven public health model for cavity prevention, and (3) achieving financial
sustainability by contracting with independent dental hygienists who are Medicaid
Providers to deliver the model’s services at no cost to the county. After only three
months of implementation, over 500 WIC clients have undergone (1) oral health
assessment by a Registered Dental Hygienist, (2) anticipatory guidance to enhance oral
hygiene behaviors, and (3) fluoride varnish treatment. This model offers impressive
public health bang for its buck and can be easily replicated in other WIC programs
throughout Colorado.
Why cavity prevention is good public health
Cavity Free at Three
Cavity Free at Three is a three-year, statewide effort to prevent oral disease in young
children. The effort aims to engage dentists, physicians, nurses, dental hygienists, public
health practitioners and early childhood educators in the prevention and early detection
of oral disease in pregnant women, infants and toddlers.
Our goal is simple: We want all children in our state to be cavity free by the time they
reach age three.
Prevalence in Colorado
Dental caries is the most common chronic childhood disease; 5 times as common as
asthma; 7 times as common as hay fever. Eighty percent of the disease is in twenty
percent of the population. It is largely a disease of poverty. Dental disease affects
children's ability to eat properly, grow, attend school and learn.
In Colorado the problem is profound,
• 18% of 2-4 year olds have dental caries; 16% have untreated decay.
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5. • 45.7% of kindergarteners have dental caries; 26.9% have untreated decay.
• 57.2% of third graders have dental caries; 26.1% have untreated decay.
• By age 17, 78% of children have had at least one cavity; 7% have lost a
permanent tooth to dental decay.
Jefferson County Public Health WIC Clinics
WIC’s mission to safeguard the health of low-income women, infants, and children up
to age 5 who are at nutrition risk by providing nutritious foods to supplement diets,
information on healthy eating, and referrals to health care. Established as a pilot
program in 1972 and made permanent in 1974, WIC is administered at the Federal
level by the Food and Nutrition Service of the U.S. Department of Agriculture. WIC is
not an entitlement program as Congress does not set aside funds to allow every eligible
individual to participate in the program. WIC is a Federal grant program for which
Congress authorizes a specific amount of funds each year for the program.
The following benefits are provided to WIC participants:
• Supplemental nutritious foods
• Nutrition education and counseling at WIC clinics
• Screening and referrals to other health, welfare and social services
WIC is effective in improving the health of pregnant women, new mothers, and their
infants. A 1990 study showed that women who participated in the program during
their pregnancies had lower Medicaid costs for themselves and their babies than did
women who did not participate. WIC participation was also linked with longer
gestation periods, higher birth weights and lower infant mortality.
JCPH houses WIC clinics at three locations throughout the county where low-income
clients who are pregnant and/or have children ages 0-5 attend scheduled nutrition
counseling appointments and pick up checks to buy food every three months.
Attending these appointments is a high priority for clients because it immediately
results in meeting the family’s basic need for food.
Public Health Cost of Dental Caries
Once established, dental caries requires treatment. A cavity only grows larger and more
expensive to repair the longer it remains untreated. Fewer than 1 in 5 Medicaid-
covered children received at least one preventive dental service in a recent year; many
states provide only emergency dental services to Medicaid-eligible adults.
Poor children have nearly 12 times more restricted-activity days because of dental-
related illness than children from higher-income families. Pain and suffering due to
untreated tooth decay can lead to problems in eating, speaking, and attending to
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6. learning. Many adults also have untreated dental caries (e.g., 27% of those 35 to 44
years old and 30% of those 65 years and older).
Removing client barriers to preventive care
Living near or below the poverty line while pregnant and/or caretaking for young
children not yet in school poses several barriers to preventive dental care.
Maslow’s Hierarchy of Needs
Maslow's hierarchy of needs
assigns priorities to five different
categories of needs common
amongst people. It is often
depicted as a pyramid consisting of
five levels: the first lower level is
associated with physiological needs,
while the top levels are termed
growth needs associated with
psychological needs. Deficiency
needs must be met first. The higher
needs in this hierarchy only come
into focus when the lower needs in
the pyramid are met.
Poverty forces people to spend much of their time and energy in pursuit of meeting
basic physical and safety needs. Nutrition, a key physical need at the base of Maslow’s
Hierarchy, is met through WIC program participation. This serves as a helpful
framework for understanding why WIC clients have much higher attendance rates for
WIC appointments than they do for preventive dental care appointments.
The time, money, and travel it takes to obtain preventive dental services are often too
great for WIC clients because those resources are needed to meet basic needs. The
JCPH model for cavity prevention service delivery enables participation by minimizing
the opportunity costs WIC clients pay to obtain preventive dental services.
Time Costs
Time spent finding a provider, making an appointment, arranging transportation, and
attending an appointment on time are significant to low-income families with small
children. This process would take an estimated 4-6 hours normally, but is reduced to
15-20 minutes in the JCPH model.
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7. Financial Costs
“It’s so fast and
easy, I feel like Low-income families often have difficulty paying for food and
I’ve done housing, and cannot divert resources from meeting those needs
something great in order to obtain preventive dental care. Often, a dental
for my child that I professional is not seen until the basic need to relieve physical
might not have pain resulting from advanced cavities or associated accesses
been able to do if I becomes a priority. The poorer a person is, the more pain they
had to pay or make will endure before seeking treatment. Further complicating a
a separate low-income client’s decision making process is that once a
appointment.” condition is serious enough to cause pain, it usually only gets
–WIC Client more expensive to treat as time progresses.
The JCPH model eliminates costs of preventive treatment, as no clients are charged
any out-of-pocket expenses. Further, treatment costs are facilitated by referring clients
to local dentists who work with low-income clients by accepting Medicaid, CHP+,
and/or participate in reduced fees and payment plans.
Travel Costs
The cost of owning and driving a car, taking a bus, or asking a friend to drive you to
and from an appointment are usually only spent on high-priority appointments
meeting basic needs amongst low-income families with children.
Travel costs are eliminated in the JCPH model by seeing clients for preventive oral
health care after their high-priority WIC appointment in the same place with no
separate appointment needed.
Delivering a public health cavity prevention model
Oral Health Promotion Meets Existing Public Health Infrastructure
Jefferson County Public Health was one of ten communities to receive the first round
of Cavity Free at Three grants in 2008. Over 200 physicians, dentists, nurses and
registered dental hygienists were trained in the program, including 35 public health
nurses and contracting registered dental hygienists at JCPH. Caring for Colorado
Foundation, The Colorado Health Foundation, The Colorado Trust, Delta Dental of
Colorado Foundation, Kaiser Permanente and Rose Community Foundation are
jointly funding Cavity Free at Three.
JCPH received funding, educational materials, clinical supplies and technical assistance
to implement the infant oral care protocol. Each grant included:
• $10, 000 for program funding
• On-site training and ongoing technical assistance on the infant oral care model
• Help in developing systems for infant oral care
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8. • Provider and patient information and education
• 500 infant oral care kits for the infant oral care exam
Staff and Contractor Training in the Infant Oral Health Model
The Cavity Free at Three Technical Assistance Team provided an onsite eight hour
technical assistance training for JCDHE public health nurses (PHN), supervisor for the
Women Infant and Children (WIC) program and local independent Dental Hygienists.
Training included:
1. Methods to incorporate an oral health risk assessment, parent education and
fluoride applications for young children into their services.
2. Methods to address the oral health needs of pregnant women and provide
them with extra education about how to care for their infant’s teeth.
3. Demonstration and hands on practice in completing oral hygiene screenings
and applying fluoride as needed to JCDHE clients 0-5 years.
Delivering the Infant Oral Health Model
Jefferson County Public Health developed a service delivery model ideal for its clients
and staff. The diagram below illustrates the relationship between the Cavity Free at
Three infant oral health clinical model and the JCPH service delivery model developed for our
county public health environment.
JCPH
WIC
Staff
JCPH Local
CHS Dental
Staff Home
Target Population
Program
Coordinator
CF3 Insurance
Service Providers
Providers
JCPH
EPSDT
Developing Local Referral Resources
Timely and appropriate referrals to dental care are essential to dental health and require
work at the local level. JCPH seeks to maximize clients’ oral health by facilitating
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9. establishment of a dental home and referring to dentists for caries treatment as early in
the disease process as possible.
Low-income clients who have Medicaid insurance or no insurance often need guidance
in finding providers who will welcome them. To solve this problem, a JCPH public
health nurse conducted targeted outreach visits to community dental service providers
who see children age 0-5 years, accept Medicaid and/or offer discounted or payment
plans for the uninsured. These providers became part of a referral list of community
dental service providers given to all Cavity Free at Three clients.
Steps to Developing Referral Resources
1. Call all area Medicaid Providers who see children as young as
12 months old.
2. Conduct Outreach Education Visits with all identified
providers to teach about the Cavity Free at Three Model and
how it will be used with WIC clients.
3. Ask for permission to add dental service provider to referral
list.
4. List payment options for each provider on list, such as
Medicaid, CHP+, discounts, and payment plans.
5. Invite dental service providers and office representatives to
participate in the education portion of the Cavity Free at
Three Technical Assistance Training Course.
6. Establish Emergency Referral Protocol with at least one dental
service provider.
7. Update Referral List on a quarterly basis.
Independent dental hygienists provide high quality
of care and financial sustainability
Colorado Practice Law for Registered Dental Hygienists
Until 1986, all state practice acts mandated some level of dental supervision for dental
hygiene practice and most required that dental hygienists be employed by dentists. In
1986, the Colorado state legislature revised the Dental Practice Law (Colorado DPL) to
permit dental hygienists to practice either supervised or unsupervised. The revised law
also permitted a dental hygienist to be the "proprietor of a place where supervised or
unsupervised dental hygiene is performed and may purchase, own, or lease equipment
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10. necessary to perform supervised or unsupervised dental hygiene" and authorized
specific services for supervised and unsupervised dental hygiene practice.
Recruiting independent RDHs
Colorado RDHs can bill Medicaid independently as part of their own dental hygiene
practice. A list of RDHs in the local area who have a Medicaid ID number and own
their own practice were called to be screened for participation. Another RDH was
identified via outreach visits with local dental offices who serve low-income children.
All RDHs were enthusiastic about obtaining such convenient and reliable access to the
WIC population and met the following qualifications: (1) be a Registered Dental
Hygienists in the State of Colorado, (2) be a Medicaid Provider, and (3) Have the
knowledge and ability to bill Medicaid/Insurance companies as part of an independent
practice not related to JCPH.
Three qualified RDHs were identified and invited to attend the Cavity Free at Three
Training in the infant preventive oral care model.
Establishing a No-Cost Contract with Incentives Sufficient to Attract and Retain RDHs
JCPH developed a no-cost contract to enter into with independent dental hygienists
for the implementation of this model. The following stipulations and incentives were
outlined:
• JCPH will provide RDHs with exam space adjacent to WIC clinic waiting
rooms at no cost. Arvada and Lakewood branches of WIC clinics see between
50 and 125 clients per day.
• RDHs will provide infant oral health model to all WIC clients whether or not
they have insurance, and can bill Medicaid for those clients who are eligible for
reimbursement.
• RDHs will administer only those services contained in the Cavity Free at Three
infant oral health model.
• Cavity Free at Three education materials and supplies will be provided by
JCPH until the 1,000 packets provided by the donor are used up.
• JCPH is not responsible for any billing or possible malpractice resultant from
RDH services provided.
Immunization Requirements
RDHs were required to meet the same immunization requirements as JCPH staff at
their own expense. Costs incurred by the RDHs ranged from $50 to $150, placing
more of a barrier to entry than anticipated. If possible, it is recommended that JCPH
absorb the cost of meeting immunization requirements as it does for its non-contract
employees.
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11. Work Space
Existing infrastructure of clinic exam rooms adjacent to WIC waiting areas offers a
unique opportunity to conveniently locate RDHs in close proximity to WIC clientele.
JCPH usually has at least one unused exam room per day, and the RDH uses left-over
exam rooms, varying according to day, in order not to disrupt clinic operations.
Supplies
Cavity Free at Three provided 1,000 kits to perform the infant oral health model, which
the RDHs divided amongst them until supplies ran out. Education materials were also
shared.
In order to obtain supplies after grant materials were exhausted, the following steps
were taken:
• Met with Diane Brunson to determine how much JCPH could reduce the cost
of the $6.18 packet developed by Cavity Free at Three while maintaining
comparable standard of care. Determinations are detailed in table below.
• Obtained educational material design files to reproduce in-house at low cost.
• Used JCPH funds to supply RDHs with masks, gloves, and chucks for exams.
(pending approval)
Cavity Free at Three Pre-Packaged Sustainability Supplies
Kits Allowing Comparable Quality of Care
1,000 Supplied by Cavity Free at Three
DuraShield 5% Sodium Fluoride Varnish, 5% Sodium Fluoride Varnish in Tube,
Bubble Fun Flavor w/Xylitol, amount to be titrated to clients’ needs.
individually packaged with disposable ($0.50-0.75/dose)
brush
24 gram tube of Kids Crest Toothpaste Large tube of ADA approved toothpaste,
amount to be titrated to client’s needs.
($0.25-0.50/dose)
Disposable oral exam mirror Reusable sterilized exam mirrors
(negligible)
Four pieces of gauze Bulk gauze to be used as needed
(negligible)
Children’s toothbrush Children’s toothbrush used only for child
clients ($1.00-2.00/client)
Parent’s toothbrush Adult’s toothbrush used only for pregnant
clients ($1.00-2.00/client)
Total: $6.18 Total: $2.00-$3.00
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12. Flexible RDH Schedules
RDHs required flexible schedules due to the need to give private practice clients
scheduling priority. Each RDH came in one to three days per week when the program
began, and eventually settled into a somewhat regular schedule. Strict RDH schedules
did not make sense, as their services were volunteer. The emphasis was placed on
establishing a positive work experience and allowing for as much Medicaid
compensation as possible while seeing all clients regardless of insurance status.
The following guidelines for WIC staff were developed to facilitate flexible RDH
schedules:
• Because the dental hygienists’ schedules need to remain flexible, they will set
up their promotional cart in the waiting area and notify WIC staff when they
are available to see clients. Referring WIC clients to the RDH is encouraged at
these times.
• Please refrain from asking clients to come back another day to see an RDH, as
we cannot be sure we will have coverage on any given day.
• When an RDH is not available, please use the CF@3 Provider Referral List to
help clients obtain dental services. All of the providers on the list accept
Medicaid and see children of all ages.
This approach resulted in an increase of RDH time spent working with WIC clients, as
demonstrated below:
Typical RDH coverage after first month of implementation:
Clinic Monday Tuesday Wednesday Thursday Friday
Lakewood All Day NO All Day Afternoon Only All Day
COVERAGE
Arvada All Day No Exam Room All Day NO NO
Available COVERAGE COVERAGE
Typical RDH coverage after third month of implementation:
Clinic Monday Tuesday Wednesday Thursday Friday
Lakewood All Day All Day All Day Afternoon Only All Day
Arvada All Day No Exam Room All Day All Day All Day
Available
Managing Client Flow
Paramount to achieving buy-in amongst WIC staff was a dedication to support their
workflow and enhance services rather than compete for clients or disrupt their
processes. This was achieved using the following guidelines:
• CF@3 screenings are to occur only after WIC appointments are finished.
However, RDHs will set up promotional carts in the waiting room, talk to
clients who are waiting for their WIC appointments, and give them paperwork
to prepare to be seen after their WIC appointment.
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13. • Clients with questions about the program can be referred to the peach
brochure provided and asked to return to the waiting room to see the dental
hygienist.
• Screenings are walk-in only at this time, so we cannot guarantee a client they
will be seen promptly.
Orienting RDHs
Program Coordinator employed by JCPH spent several days in clinic full-time with
each RDH to introduce them to staff, help manage client flow while they became
comfortable with the infant oral health model, facility, and supplies, and helped
promote program to both WIC staff and WIC clients.
Orienting WIC Staff
WIC manager was approached for collaboration before the model was developed. Staff
was notified that the services would be integrating by their manager. Program
Coordinator and RDH educated WIC staff about services offered and requested
feedback about process. WIC staff was overwhelmingly supportive of program and
enthusiastically referred clients after WIC appointments.
Pathways for Ongoing Communication
Developing direct professional contact between RDHs and WIC staff is imperative to
healthy communication amongst front-line service providers. Each RDH was both
motivated and professional in developing and maintaining these relationships to
increase referrals and maintain optimal patient flow. Occasionally, WIC staff brought
up an issue or two with their manager, who then passed that issue to the Program
Coordinator to bring up with the RDH. For instance, one WIC counselor was asked
to postpone an appointment to translate for the RDH and did not feel comfortable
declining even though that was interfering with her work. This was resolved by
establishing firm boundaries with the RDHs and reinforcing that the clinic’s main
purpose is to deliver WIC services unimpeded and it is up to the RDHs to
accommodate their needs.
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