The goal of Integrating HIV Innovative Practices (IHIP) is to enable health care providers to implement proven innovations in HIV care and services within their own practices. This Webinar is the second in a three-part series exploring innovative approaches to delivering oral health care and services to people living with HIV/AIDS, featuring grantees of the Health Resources and Services Administration’s Special Projects of National Significance (SPNS) Innovations in Oral Health Care Initiative (Oral Health Initiative). This Webinar outlines dental case management programs at the AIDS Care Group (ACG) in Chester, PA and the Native American Health Center (NAHC) in San Francisco, CA. The presenters include Dr. Howell Strauss and Mr. Nelson Diaz from ACG; and Dr. Carolyn Brown and Ms. Lucy Wright, RDH, representing the NAHC. The presentation details the pros, cons, and considerations of dental case management from administrative and clinical perspectives. The presenters also provide tips for being a good dental case manager and how this can result in improved health outcomes.

1. SPNS IHIP Oral Health Webinar Series:
Dental Case Management
……………….
Presented by Dr. Howell Strauss and Nelson Diaz of AIDS Care Group
and Dr. Carolyn Brown and Lucy Wright of the Native American Health Center
January 9, 2014

2. Agenda
■
Introduction to SPNS Integrating HIV Innovative
Practices (IHIP) project
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■
Sarah Cook-Raymond, Managing Director of Impact Marketing
+ Communications
Presentations
■ AIDS Care Group of Chester, PA
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Native American Health Center of San Francisco, CA
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Dr. Howell Strauss, Executive Director & Dentist
Nelson Orlando Diaz, Dental Case Manager & Community
Health Worker
Dr. Carolyn Brown, Dental Director, Programs &
Development
Lucy Wright, RDA, Dental Program Coordinator & Former
Patient Navigator
Q&A

3. IHIP Resources on
TARGET Center Website
www.careacttarget.org/ihip

4. IHIP Oral Health Resources
■Training
Manual
■Curriculum
■Pocket
Guide
■Webinar
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Series
Healthy Mouth, Healthy Body (Held Dec. 13)
Dental Case Management
Clinical Aspects of Oral Health Care for PLWHA
Recording and slides for all Webinars will be uploaded to
TARGET Center Web site following the live event:
www.careacttarget.org/ihip

5. Other IHIP Resources
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Buprenorphine Therapy
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Engaging Hard-to-Reach Populations
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Training Manual, Curriculum, and Webinars on engaging hardto-reach populations
Jail Linkages
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Training Manual, Curriculum, Monograph, and Webinars on
implementing buprenorphine in primary care settings
Training Manual, Curriculum, Pocket Guide, and Webinars on
enhancing linkages to HIV care in jails settings
UPCOMING: Hepatitis C Treatment Expansion
■
In Spring/Summer 2014, look for training materials on increasing
access to and completion of Hepatitis C treatment for PLWHA on
the TARGET Center Web site.

6. AIDS Care Group
Outreach and Dental Case
Management

7. Clinical services
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Medicine
Dentistry
Medical case management
Nutrition
Psychiatry
Psychosocial services

9. Social and Medical Factors Affect
Individual and Community Health
There is poverty, joblessness, homelessness,
and despair.
Crime, substance abuse behaviors, and/or
mental health conditions affect access to
and retention in care.
Dental care historically lacking in this targeted
population.

10. Historical Review of Access to
Dental Care
 1980s: Regardless of ability to pay, dental
care was inaccessible.
 Early 1990s: One of two dental schools in
Philadelphia accepted HIV positive patients.
 Middle 1990s: Americans with Disabilities
Act: All dental practices are offices of public
accommodation.

11. History continues
 New ways devised to deny dental care:
“This office does not accept Medicaid dental
insurance.”

12. Barriers to Care
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Fear of the dentist
Inability to pay
Need to be asleep
No way to get there
Other family and health issues

13. Newly Constructed Barriers
 To get care in the Ryan White setting, you
must present your papers.
 “Papers, please.”

14. Special Projects
The AIDS Care Group was awarded
a Special Projects of National
Significance grant for
“Oral Health Care – Outreach
Project”
A new clinic was established in Coatesville in October, 2006

30. Dental Case Management
 Outreach stresses the need to go where people are
receiving the most basic of their needs.
 It can mean meeting people in hospitals, food distribution
centers, religious meeting places, or social service
agencies. It can also mean meeting people in prisons and
jails, drug and alcohol treatment centers, or crack-houses.
 The dental case manager is the glue that keeps the
program together.

31. Linked patients, papers, and providers.
Liaison between medical and social
services providers, family members, and
dental staff.
Transportation: New van logged 35,000
miles in first year of operation; exclusively
for the dental outreach program.
Other enhancements: food, clothing, gas
cards, chief kibbitzer.

32. 
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New dental clinic established.
New dentist hired.
Staff added from the community.
Outreach provided to multiple communities.
Start-up time: 4 months.
Full patient schedule within 6 months.
Over 600 patients treated.

33.  Program sustained to this day, using the
same model of outreach and removing
barriers to care.

35. 2014 HRSA/SPNS IHIP
Dental Case Management Webinar
Native American Health Center
Carolyn Brown, DDS
Dental Director
Carolynb@nativehealth.org
Lucy Wright,RDA
Dental Program Coordinator
Former Patient Navigator
Lucyw@nativehealth.org

36. Building the Case for NAHC’s
Patient Navigator (Pre-2006)
 Wide range of dental services offered at NAHC
– Compact dental team focusing on clinical services
 Referrals for HIV+ persons from 14+ agencies to NAHC
dental
 Sporadic success in managing dental treatment
– Sometimes resulted in incomplete appointments, missed
appointments
– Confusion on the part of the patient, NAHC and referring agency
– Dentist or over burdened receptionist often requesting + med info
– Most treatment plan completions for patients with the least
amount of access issues
– 35% no-show rate for dental appointments from HIV+ patients
referred from partner agencies1
1- Goddard G, Brown C, and Ahmad S: Oral Disease Prevalence among HIV-Positive Native American Indians
in an Urban Clinic, Journal of Psychoactive Drugs, Vol 37 (3), Sept 2005. PMID: 16295015

37. Creating Dental Case Management
The chicken or the egg?
Option 1:
Dental staff and train for case management
Option 2:
Case manager and upgrade dental i.q.

38. Patient NavigatorGOALS
 Increase Access
– Identify barriers to care during interviews, and treatment;
customize support or ancillary services
 Intro the idea of a dental home
– Patient will identify with NAHC, their dentist, and dental case
manager as THEIR provider, fostering understanding and
motivation towards treatment plan completion
 Build Team Mentality
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Build cohesiveness of the dental team
Bridge resources with medical case managers
Bridge resources for referrals
Partner w. the patient, and care givers to meet their needs and
accomplish their dental goals
– Identify other medical or community resources for the patient

39. Patient NavigatorA Day in the Life of…
9a -HIVQUAL audit prep
930a- Pick up food from Food Bank
10a- Accompany patient to the oral surgeon
11a- Call 10 patients for appt reminder; Remind 1 patient to bring
lab work
1130a-Coordinate with oral sx’s office on patient’s f/u instructions
12p- Answer patient’s email who is confused about appt time;
review incoming faxes and lab work
2p- Intake 2 new patients; f/up with 1+
3p- Meet with DDS to review tx plan progress
4p- Review treatment plans with DDS
430a- Call patient from oral surgery appt; follow-up
5p- Meet with 1 patient after dental appointment

40. Findings from the SPNS projects
Clinical:
Improvement in overall
health status
More likely to complete
Phase 1 treatment plans
More likely to be retained
in dental care
Patients:
Availability of DCM
Increase access
Knowledge
Empathy and offer comfort
Patients credited overall
health improvement to DCM
LeMay, Tobias, Umez-Eronini, Brown,McCluskey, Fox, Bednarsh and Cabral.Dental case manager encounters: the association with retention in
dental care and treatment plan completion. Spec Care Dentist. 2013 Mar-Apr;33(2):70-7.
LeMay, Cashman, McDonald, Graves. A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager.
Prev Chronic Dis. 2012;9:E158.

41. NAHC HOPE/SPNS Study
2007- 2010 Results
 DCM (n= 85) and non-DCM patients (n=205)
very similar populations
 DCM patients had significantly higher:
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Phase 1 treatment plan completion
Low intensity preventative treatments
Higher number of dental appointments/yr
Higher likelihood of keeping appt.
Higher reported oral health quality of life
Brown C, Ponnala S, Kim J. Oral Presentation: “Maximizing Clinical and Health Outcomes: HIV+ Dental Case Management”. International
Association for Dental Research, Miami, FL. April 1-4, 2009.

42. NAHC’s Patient Navigator Success
 No show rate for HIV+ dental patients at 5%
from 35% over 4 years
 118 patients who have been out of care recruited
and retained
 88+ specialty referral appointments kept and
treatment received
 Close partnership with 10 medical clinics
specializing in HIV+ care
 Added 2nd Dental Case Manager; Ratio was 40-50
patients : 1 DCM

43. The State and Future of HIV
Research Goal #3: Optimizing
treatment and care of the
HIV-infected individual
“I never really had good teeth, but my T cells have
actually gone up to 600 since I’ve been here getting my
teeth fixed. My health improved so much; I’m so
grateful! I never realized that I needed help in getting
here. I love Lucy, my DCM.” Mike M.

44. Strategies for Success
NAHC SPNS Team
Sridevi Ponnala, DDS, Clinical Director
Carolyn Brown, DDS, Dental Director
Eulalia Valerio, Director, Projects & Evaluation
Lucy Wright, RDA, Dental Patient Navigator
Gloryanna Valerio-Leonce, Data & Intake Manager

45. Next Oral Health Webinar
Clinical Aspects of Oral Health Care for PLWHA
January 22, 2014 at 3 PM EST
More information available at:
https://careacttarget.org/library/clinical-aspects-oral-hea
•
Presenters:
•
•
Dr. David Reznik, HIVDent and Grady Health System of
Atlanta, GA
Ms. Helene Bednarsh, RDH, MPH, HIVDent and Boston
Public Health Commission of Boston, MA

46. Q&A
To be informed about Webinars and other upcoming IHIP
resources, sign up for the IHIP listserv by emailing
scook@impactmc.net.
IHIP Web site: www.careacttarget.org/ihip
Connect with Us
Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications
Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300