Dental Care in Exchange for Community Service, Program Works

Laird Harrison

September 17, 2013

Requiring indigent patients to do community service in exchange for their dental care can reduce their reliance on emergency rooms, a new study shows.

Emergency room visits for dental pain in Calhoun County, Michigan, have dropped by 70% since the start of a new program called the Calhoun County Dentists' Partnership, researchers report in the September issue of Health Affairs.

Patients can gain self respect as well as better oral health through the program, first author Raymond J. Higbea, RN, PhD, told Medscape Medical News.

"This is a group who have always been told they can't do anything," said Dr. Higbea, a professor of public affairs and administration at Western Michigan University in Kalamazoo.

Dentists like the program because they have less paperwork to do than they would with government programs and because patients are more likely to show up on time for appointments, he said.

"It's been incredibly successful and effective," Tom Kochheiser, a spokesperson for the Michigan Dental Association, told Medscape Medical News.

The proportion of the 72 private-practice dentists listed by the Calhoun County Dental Society who participate in the program grew from 14% in 2007 to 60% in 2012.

The program originated from a discussion in a coalition of healthcare groups in the county, who noticed that more and more patients with dental pain were coming to the Bronson Battle Creek Hospital emergency department. Physicians in emergency rooms are typically ill equipped to address the root source of dental pain.

Now dental patients showing up at the emergency room get a referral to the Calhoun County Dentists' Partnership.

There, the staff verifies that they meet the criteria for inclusion in the partnership: patients cannot earn more than 200% of the federal poverty level ($22,980 for an individual in 2013), and they cannot have dental insurance.

If they qualify for Medicaid, the staff helps them fill out enrollment paperwork on the spot and refers them to the local federally qualified health center. That center has had to double the number of its dental chairs from 10 to 20 since the program started because of the influx of new patients, said Dr. Higbea.

If the patients do not qualify for Medicaid, the staff enrolls them in a 2-hour class with a hygienist who instructs them in preparing for their dental visit; for example, by being on time and brushing their teeth, being courteous to the staff, and writing a thank-you note to the dentist.

People who are having a dental emergency can skip the intake procedures and get an immediate appointment with a dentist.

The other patients get a dental screening by a hygienist at a free clinic, including a cleaning, appropriate X-rays, and clinical notes. The patients must then complete 4 hours of volunteer service for every $100 of dental treatment. People who cannot perform the service themselves can get a family member or friend to do it for them.

A community agency coordinates the volunteer assignments, which vary widely. "It can be anything," Dr. Higbea said. "It could be [working at a] food bank. There was one lady who chose to knit scarves." Some patients have gotten jobs as a result of their volunteer work, he said.

The community agency follows-up to verify the patients have completed their service before they can see a dentist.

Dentists volunteer to participate in the program and see patients at their own offices. If they determine the patient needs additional services, the patient can do additional community service in exchange. If the additional care a patient needs exceeds the number of hours the dentist has agreed to commit to the program, the dentist can refer the patient to another participating dentist.

Paying for the visit in advance with their community service makes the patients more motivated to keep appointments, Dr. Higbea said. Patients in the program miss only 2.5% of their appointments compared with 20% for commercially insured patients, the researchers found.

Between 2007 and 2012, the proportion of emergency visits for dental pain has declined from 26.5 visits per 1000 emergency department visits to 7.5 visits, a change that is statistically significant (P < .0001).

In addition, the researchers found that patients are less likely to return to emergency rooms for dental care. Starting at a range of 1.24 to 1.41 emergency department visits per patient, the number of these visits has declined to between 1.01 and 1.08 per patient since then, they reported.

The number of dental visits per patient has not changed much in that time, Dr. Higbea said, dropping only slightly from a high of 1.98 in 2007 to an average of 1.71visits. Together, the 2 statistics mean patients are getting care just as often but are more likely to get it in the right place, he said.

The number of patients participating has grown substantially from 228 in 2007 to 771 in 2012.

The program has cost $150,000 a year ($900,000 during its 6 years), which includes hiring a single full-time administrator and paying the hygienists. A variety of local grants and private gifts have paid these expenses, the researchers said.

Dr. Higbea and colleagues estimated that the care donated by dentists at $943,053, but they figured the value of the community service work donated by the volunteers (computed at $25 per $100 of dental charges) to be worth $1,443,650.

The program is so successful that other Michigan counties are trying it, Kochheiser noted.

Kochheiser and Dr. Higbea have disclosed no relevant financial relationships.

Health Affairs. 2013;32:1646-1651. Abstract

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