Survival Strategies for Safety Net Dental Clinics by Frank Beck

1. SURVIVAL STRATEGIES FOR SAFETY NET
DENTAL CLINICS
THURSDAY OCTOBER 20, 2011
M. Frank Beck, DDS, FAAHD, MAGD, FICOI, DSCDA
Dental Program Director

4. Catholic Healthcare Partners
CHP

6. St. Elizabeth Health Center
Ambulatory Care Center
Description:
•Internal Medicine Clinics
•Pediatric Clinic
•Women’s Health Center
•Pre-Natal Clinic
•Gynecological Clinic
•Surgical/Trauma Clinic
•Ambulatory Care Pharmacy
•WIC Program
•Prescription Assistance Program
•Specialty Clinics

7. Ambulatory Care Center
Purpose of Service
1. Provide health services to the ambulant
patient of low income, no insurance and under
insured referrals from other
physicians, surgeons, Family Health Center
(but not limited to this group).
2. Provide for diagnosis and treatment of disease
entities.
3. Provide preventive health education and
promote wellness on patient and family basis.
4. Provide education and training opportunities
for Ambulatory Care medical residents and
medical/nursing students and related health
professions.

8. Mission Statement
The mission of the Ambulatory Care Center is to provide individuals with health
care, which includes prevention, diagnosis, treatment, and education regardless of their
economic status. We are committed to delivering high quality medical care to everyone
in need, with an emphasis on the poor and underserved residents within the community.
As a teaching facility for the residency programs, the Ambulatory Care Center is also
devoted to providing residents and students an education that emphasizes proper
medical treatment as well as concern and respect for our patients and community.
The Ambulatory Care Center is part of the Humility of Mary Health Partners, which
continues the healing ministry of the Sisters of Humility of Mary.

9. Adj : Grades of excellence

10. Hospital-Based General Practice
Safety Net Dental Residency
Dental Clinic Program

11. SCOPE OF SERVICES PROVIDED
Mobile Inpatient Emergency Communit
Dental Operatin
Dental Floor Departmen y
Clinic g Room
Vans Consults t Consults Education
Floor Emergency
Follow-ups Follow-ups

12. SCOPE of SERVICES PROVIDED
DENTAL MOBILE
CLINIC DENTAL
VANS

13. INPATIENT FLOOR CONSULTS
FOLLOWUP TREATMENT
EMERGENCY ROOM CONSULTS
FOLLOWUP TREATMENT
 The dental residents/ faculty provide coverage for 24 hour emergent care.
 This enables dental pathology to be intercepted and treated at an earlier stage of
progression.
 Early interception of dental pathology prevents fulminant progression and
extension to involve and exacerbate existing systemic co-morbidities.
 Not only does this reduce risk for the patient, but also significantly reduces cost to
the hospital facility by preventing multi-organ system involvements.

14. LEVEL ONE TRAUMA CENTER

15. OUTPATIENT ORAL SURGICAL/GENERAL DENTAL
PROCEDURES IN THE MAIN OPERATING ROOM
 One of only three sites in the tri-county area to provide for comprehensive
dental needs for the mentally-challenged, developmentally
disabled, pediatric and frail/elderly.
 CDC data clearly demonstrates that people with disabilities and complex
health conditions are at greater risk for oral disease.
 Early access to dental care will obviously prevent the progression of dental
disease to a more fulminant pathology.
 However, less obvious is the fact that early access to dental care will also
prevent the fulmination of coexisting systemic disease such
as, CV, DM, HBP.

16. COMMUNITY EDUCATION
The faculty, residents and staff educate the
community regarding oral health and provide
direction so members of the community may access
the dental services they need.

18. SYSTEMS OF MANAGEMENT
 Ensure Consistent Delivery of
Care
 Ensure Continuity of care

19. DEVELOP AND IMPLEMENT
POLICIES AND PROCEDURES

20. DEVELOP/IMPLEMENT
INSTRUMENTS TO
MEASURE & EVALUATE
PERFOMANCE

21. PERFORMANCE PARAMETERS
SAFETY NET RESIDENT
PATIENT CARE
DENTAL CLINIC EDUCATION
Individuall Collectivel
Faculty Residents
y y

22. DENTAL CLINIC PERFORMANCE MEASURES
Gross Charges Expenses # of Visits Rev per Cost per visit # of Unduplicated New pts # of Transactions/ No-Show Rate Emerg Rate # Children TOTAL # sealants
Baseline visit Pts visit receiving sealants applied
<21
3 mo
6 mo
9 mo
12 mo
15 mo
18 mo
21 mo
24 mo
# of completed
DDS RDH CDA treatments TPC’s 1-30 31-60 61-90 91+ Medicaid Sliding Fee 0 Sliding Fee Commercial Ins Other
** pay Scale
Sliding Fee
20% or more
3 mo
6 mo
9 mo
12 mo
15 mo
18 mo
21 mo
24 mo

23. DENTAL CLINIC PERFORMANCE MEASURES
Gross Expense # of Rev Cost per # of New # of No-Show Rate Emerg # Children TOTAL #
Baseline Charges s Visits per visit Unduplicated pts Transactions/ Rate receiving sealants
visit Pts visit sealants applied
<21
3 mo 2.64
6 mo 2.68
9 mo 2.50
12 mo 3.42
15 mo 3.27
18 mo 3.42
21 mo 3.7
24 mo

24. # OF TRANSACTIONS/VISIT
 2.64  3.7
 40% increase!

25. AVG # PROCEDURES/ENCOUNTER
 Ohio Safety Nets
 2.4

26. RELATIVE ANNUALIZED # PT VISITS
 3665 Pt Visits / 6months (3.7 vs. 2.4)
 Effectively Translates 5650 Pt Visits

27. NET RESULT OF INCREASE #CPT/VISIT
 Increase Revenue/Visit
 Decrease Cost/Visit
 Increase Sustainability

28. OPERATORY TURNAROUND
 Disinfect/Set-up Operatory
 Meet/Greet/Seat Patient
 Procedure (procedures)**
 Operatory Breakdown
 Dismiss patient
 Documentation

29. Additional Considerations
 Economy of Time
 Economy of Materials
 Favorable Ergonomics - by
minimizing repetitive tasking

30. HOW do we accomplish this?
Conversion of OBSTACLES into
OPPORTUNITIES

31. OBSTACLES
•No Show Rate
•Transportation Barriers
•Re-Appointment Intervals
•Follow-Up Compliance

32. INCORPORATION OF OPEN/CLOSED DENTAL
APPT CONCEPTS
 Quadrant dentistry for those sitting in chair
when next patient no shows.
 Continuation of serial appointments
 Conversion of emergency appointments to
definitive care.

33. DENTAL CLINIC REVENUE SOURCES
IME/DME Medicaid DSH In Kind Support HMHP
Baseline EAGLESOFT Med Floor $564,000 DME Anthem ODH CHP HMHP 1000 ACC/R HRSA HRSA Curr In Kind Grant Totals
Cross Consults 100,000 65,00 25,00 112,000 F Equip Grant Support HMHP
Coding 1500 Totals
0 0
Facility Fees Professional Fees
ER
GRANTS
3 mo 76,125
6 mo 76,125 ***
9 mo 1st 76,125 ***
Med Cross
12 mo 2nd
Coding
15 mo 3rd
18 mo 4th
21 mo
24 mo

34. DEFINITIVE CARE DENTISTRY
 Only a dentist is trained and licensed to
provide the DEFINITIVE CARE that the oral
health needs of Ohioans require
 Without access to the definitive care
provided by the dentist, many patients have
sought care in a more costly setting such as
a hospital emergency room.

35. DEFINITIVE DENTAL CARE CONT’D
 Treatment of patients requiring dental care in
a hospital emergency room generally
consists of little more than two prescriptions:
 An antibiotic for infection
 An analgesic for pain
 Thus, the patient receives only symptomatic
relief and re-enters the system in the future
presenting more fulminant pathology,
requiring the utilization of even more
resources

36. DEFINITIVE DENTAL CARE CONT’D
 In some cases the results of poor dental care have
been deadly. A child in Mississippi and another in
Maryland died in 2008, as a result of infections
caused by decayed teeth.
 A similar life-threatening situation presented to SEHC
Dental Clinic late in 2008 when a high risk 3rd
trimester female presented to the dental clinic with
multiple decayed and abscessed teeth.
 OB/GYN consultation was obtained, appropriate
medications prescribed and surgery scheduled
 The patient did not show for surgery
 Next presentation to EOR via ambulance in coma

42. UNNECESSARY
VISITS IN THE
EMERGENCY ROOM

43. METHODS
 Level I and II visits at SEHC Main ED from 10/07
thru 08/08 were analyzed (n = 3,088). Data
provided by S. Rivello.
 Each encounter ICD9 diagnosis was reviewed to
ascertain its necessity as a ED visit (by DG). Any
encounter with associated procedures was
considered necessary.
 Variables analyzed included self pay status,
demographics, charges, and temporal variability.

44. Vaginitis 6
UTI 10
Gout 10
Other sprain 12
Cervicalgia
Viral/ varicella
13
16 UNNECESSARY ED VISIT BY
TOP 30 DIAGNOSIS ICD9
Bipolar/ depression/mental health 16
Other 18
Anxiety 18
Chronic pain 19
Dressing change/ sutures 20
Earwax 22
Sinusitis/ rhinitus 22
Joint pain/ osteoarthritis 24
Hypertension 26
Pharyngitis/ Nasopharyngitis/strep 27
Bronchitis/ asthma 27
Repeat prescription 30
Scabies 31
Limb cramp/ myalgia 31
Hives 33
Allergy 35
STD/ VD/ HIV testing 40
URI/ cough 40
Backache/ lumbago/ disc 60
Conjunctivitis/blepharitis/chalazion 85
Back sprain 92
Otitis media 154
Dermatitis 180
Dental 391

45. DEVELOPMENT AND IMPLEMENTATION
OF DEFINITIVE CARE CLINIC
Our experiences in providing access to oral health care has
clearly demonstrated that the PRIMARY motivating factor
responsible for our patient population seeking care is PAIN not
PREVENTION

46. ER CONSULT BY DENTAL RESIDENT
 Rx Antibiotic
 Rx 1-2 Analgesics
 LA Injection
 Appt 700am following day

49. INSTITUTIONAL QUALITY OF CARE
 Render definitive care
 Most appropriate venue
 Most cost effective manner

50. PERFORMANCE PARAMETERS
SAFETY NET RESIDENT
PATIENT CARE
DENTAL CLINIC EDUCATION
Individuall Collectivel
Faculty Residents
y y

51. PATIENT CARE QUALITY ASSESSMENT
Collectively Individually

52. COLLECTIVELY
 Community Impact
 Performance measures

53. DENTAL CLINIC PERFORMANCE MEASURES
Gross Charges Expenses # of Visits Rev per Cost per visit # of Unduplicated New pts # of Transactions/ No-Show Rate Emerg Rate # Children TOTAL # sealants
Baseline visit Pts visit receiving sealants applied
<21
3 mo
6 mo
9 mo
12 mo
15 mo
18 mo
21 mo
24 mo
# of completed
DDS RDH CDA treatments TPC’s 1-30 31-60 61-90 91+ Medicaid Sliding Fee 0 Sliding Fee Commercial Ins Other
** pay Scale
Sliding Fee
20% or more
3 mo
6 mo
9 mo
12 mo
15 mo
18 mo
21 mo
24 mo

54. INDIVIDUALLY
 HMHP Physician Practice
 Satisfaction Surveys
Quarterly

60. PERFORMANCE PARAMETERS
SAFETY NET RESIDENT
PATIENT CARE
DENTAL CLINIC EDUCATION
Individuall Collectivel
Faculty Residents
y y

61. RESIDENT EDUCATION QUALITY ASSESSMENT
CODA Resident Resident QT Eval of QT Faculty
Standards Continuous Repetition Residents by Evals
QA/QI Sign off Faculty
Sheets
Residents DME

62. CODA STANDARDS

63. CODA STANDARDS
 Table of Contents PAGE
 Mission Statement of the Commission on Dental Accreditation .............................................. 2
 Accreditation Status Definitions .................................................................................................. 3
 Introduction ................................................................................................................................. 4
 Goals ............................................................................................................................................. 6
 Educational Environment ............................................................................................................ 9
 Definition of Terms Used in Accreditation Standards ............................................................ 14
 Accreditation Standards for Dental Education Programs ...................................................... 17
 1- Institutional Effectiveness ............................................................................................ 17
 2- Educational Program.................................................................................................... 20
 2-1 Instruction ............................................................................................................. 20
 2-3 Curriculum Management ...................................................................................... 20
 2-9 Critical Thinking ................................................................................................... 22
 2-10 Self-Assessment .................................................................................................... 23
 2-11 Biomedical Sciences ............................................................................................. 23
 2-15 Behavioral Sciences .............................................................................................. 24
 2-17 Practice Management and Health Care Systems .................................................. 25
 2-20 Ethics and Professionalism ................................................................................... 25
 2-21 Clinical Sciences ................................................................................................... 26
 3- Faculty and Staff ........................................................................................................... 29
 4- Educational Support Services ...................................................................................... 30
 4-1 Admissions ............................................................................................................ 30
 4-5 Facilities and Resources ........................................................................................ 30
 4-6 Student Services .................................................................................................... 31
 4-7 Student Financial Aid ........................................................................................... 31
 4-9 Health Services ..................................................................................................... 31
 5- Patient Care Services .................................................................................................... 33
 6- Research Program ........................................................................................................ 35

64. CODA STANDARDS
 Mission Statement of the Commission on Dental
Accreditation
 The Commission on Dental Accreditation serves the
public by establishing, maintaining and applying
standards that ensure the quality and continuous
improvement of dental and dental-related education
and reflect the evolving practice of dentistry. The
scope of the Commission on Dental Accreditation
encompasses dental, advanced dental and allied
dental education programs.
 Commission on Dental Accreditation
 Revised: January 30, 2001

65. RESIDENT CONTINUOUS QA/QI
PARTICIPATION

69. RESIDENT STEP REPETITION SIGN OFF SHEETS

77. QT EVAL OF RESIDENTS BY FACULTY
ST. ELIZABETH HEALTH CENTER
EVALUATION OF COMPETENCIES
GENERAL PRACTICE DENTAL RESIDENCY PROGRAM
Resident: ___________________ Evaluation Period: _________________
Faculty: ______________________________________________ Date:_________________________
Faculty Signature:_______________________________________
Please circle the number corresponding to the resident’s performance in each area.
Unsatisfactory= Several behaviors performed poorly or missed (rating 1, 2 or 3)
Satisfactory= Most behaviors performed acceptably (ratings 4, 5,or 6); satisfactory performance is described below)
Superior= All behaviors performed very well (ratings 7,8, or 9)
Unsatisfactory Satisfactory Superior
Professionalism
1. Demonstrates integrity and 1 2 3 4 5 6 7 8 9
ethical behavior; Accepts Takes responsibility for actions willingly; admits mistakes; puts patient
responsibility and follows needs above own interests; recognizes & addresses ethical dilemmas &
through on tasks conflicts of interest; maintains patient confidentiality; is industrious &
dependable; completes tasks carefully & thoroughly; responds to
requests in a helpful & prompt manner.
2. Practices within the scope 1 2 3 4 5 6 7 8 9
of his/her abilities Recognizes limits of his/her abilities; asks for help when needed; refers
patients when appropriate; exercises authority accorded by position and/or
experiences.
3. Demonstrates care and 1 2 3 4 5 6 7 8 9
concern for patients and Responds appropriately to patient & family emotions; establishes rapport;
their families regardless of provides reassurance; is respectful & considerate; does not rush; is sensitive
age, gender, ethnicity or to issues related to each patient’s culture, age, gender & disabilities; provides
sexual orientation; Responds equitable care regardless of patient culture or socioeconomic status.
to each patient’s unique
characteristics and needs
Interpersonal & Communication Skills
4. Always demonstrates integrity, respect 1 2 3 4 5 6 7 8 9
compassion, and empathy for patient.
Establishes trust. Primary concern is for
the patient’s welfare. Maintains credibility,
excellent rapport with patients and families.
5. Communicates effectively 1 2 3 4 5 6 7 8 9
with other healthcare Maintains complete & legible medical records; writes clear & concise
professionals consultation reports & referral letters; makes organized & concise
presentations of patient information; gives clear & well-prepared
presentations.
6. Works effectively with 1 2 3 4 5 6 7 8 9
other members of the Demonstrates courtesy to and consideration of consultants, therapists,
healthcare team & other team members; invites others to share their knowledge & opinions;
makes requests not demands; negotiates & compromises when disagreements
occur; handles conflict constructively.
Dental Knowledge
7. Extensive and well applied. Knowledge 1 2 3 4 5 6 7 8 9
Of disease, pathophysiology, diagnosis and
Therapy. Consistently up-to-date. Self-
Motivated to acquire knowledge.
8. Identifies all the patient’s problems. 1 2 3 4 5 6 7 8 9
Interrelates abnormal findings with altered
dental pathology. Establishes sensible
differential diagnoses. Provides orderly
succession of testing, therapeutic recommendations

80. QT EVAL OF FACULTY BY RESIDENTS
S t. Elizabe th He a lth Ce n te r
D e p a rtm e n t Of D e n ta l Ed u c a tio n
EVALU ATION of CORE FACU LTY by RES ID EN TS
Ac a d e m ic Ye a r: 2011-2012 D a te s :_ J u ly – Oc to be r 2011______
P lea se eva lu a t e t h e fa cu lt y list ed below, r a t in g in a ll of t h e ca t egor ies or in dica t in g N/A.
F a c u lty N a m e _________________
TEACHIN G CATEGORIES Ex c e lle n t Go o d F a ir P oor N /A
1. Tea ch in g E n t h u sia sm
2. Over a ll Tea ch ing Abilit y
a . Ba sic Scien ce
b. Clinica l Scien ce
c. Lect u r e Con t en t
d. Oper a t in g Room
e. Con fer en ce At t en da n ce
f. Con fer en ce P a r t icipa t ion
3. Wer e t h er e per son a lit y con flict s? Yes No
If yes, plea se expla in :
4. Recom m en da t ion s/com m en t s:
RE SIDE NT _____________________SIGNATURE _________________________________
P le a s e re tu rn to La ris s a Mc E lra th , D e n ta l Ed u c a tio n AS AP
E va l. by Res.-of Core F a cu lt y (qt.

81. DIRECTOR OF MEDICAL EDUCATION
• Completes Statistical Analysis and Evaluation
• Faculty/Resident Retention, Advancement or Termination