Oral Health America Webinar Series
Understanding Dental Therapy in Minnesota: A Focus on Workforce and Case Studies
December 14, 2017
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/Oral Health America
@Smile4Health
HOUSEKEEPING INFORMATION • •
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• •
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CE Credit Available
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CAMPAIGN FOR ORAL HEALTH EQUITY Addresses oral health inequities in our society and identifies possibilities for closing the oral health divide in America.
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Laura McLain, MPA
Senior Research Analyst, Minnesota Department of Health
Deborah Jacobi, RDH, MA Policy Director, Apple Tree Dental
Dental Therapists in Minnesota
History Recap • 2008
MN Legislature charters Work Group
International site visits • 2009
Licensing law passes, education begins
• 2011
First graduates, practice begins
• 2014
First state evaluation published
• 2016
Education changes Dual dental therapy/dental hygiene at both schools
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Background • Dental Therapists: evaluative, preventive, restorative and minor surgical dental care under the direction of a dentist. • Serve low-income, uninsured and underserved patients, or practice in a dental health professional shortage area.
• Advanced Dental Therapists: After 2,000 hours and passing certification exam. • Additional services provided: oral evaluation and assessment, treatment plan formulation, non-surgical extraction of certain diseased teeth. • Dentist need not be on site or see patients before they receive care. 12/13/2017
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Background • Must have a collaborative management agreement (CMA) with a dentist. • Covers how the DT and dentist will work together, scope of practice, and supervision. • Many are also dental hygienists, also called “dually licensed.”
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Education • Education – Originally bachelors or Masters degree; Advanced Dental Therapists need additional certification. • Education programs: Adjusting to best meet needs • University of Minnesota: trains students in both dental hygiene and dental therapy.
• Originally offered BA and MA; switched to MA in 2016 • Metropolitan State University/Normandale Community College: MA in dental therapy.
• A BA in dental hygiene required for acceptance in to program. • Exploring options for rural location 12/13/2017
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Ongoing: Minnesota and DTs • Board of Dentistry: Manages licensing and regulatory process • Profession: MN Dental Therapy Association • Minnesota Department of Human Services (DHS): Medicaid • Minnesota Department of Health (MDH)
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MDH: Office of Rural Health and Primary Care • Role in supporting legislative process • Initial evaluation study • Toolkit & TA especially to early adopters • On-going workforce surveys • DT research stakeholder group
• Loan forgiveness program 12/13/2017
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Adoption Curve 77 licensed dental therapists as of Nov. 2017
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2014 2014 Evaluation Study Methods & Limitations • Methods: • Dental therapist licensing data • Survey of 1,382 dental therapist patients • Interviews with clinics employing dental therapists • Clinic administrative data • Oral health-related emergency room usage data
• Limitations: Small number of DTs and no ADTs at the start of the study. Innovator/early adopter clinics still in the “figuring out” phase. 12/13/2017
Photo: Thedailystar.net
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2014 2014 Evaluation Study Findings • DT workforce serving low-income, uninsured and underserved patients. • DTs appear to be practicing safely. Clinics reported improved quality.
• Savings made it possible to expand capacity. Clinics saw more new patients, mostly underserved. • DTs allowed for more flexibility and efficiency in scheduling patients. • Some patients reported shorter wait times for appointments. 12/13/2017
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2014 2014 Evaluation Study Findings, continued • Benefits included direct costs savings, team productivity, improved patient satisfaction and lower fail rates. • Start-up was varied: employers expected continuing evolution.
• DTs have potential to reduce unnecessary ER visits. • Because of the differential between state rates and clinics’ lower costs for employing DTs, it appears DTs are contributing to more patients being seen. • With same payment rates for DDS & DT, no immediate savings to the state on each claim paid. 12/13/2017
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DT Employer Toolkit • MN produced emerging professions toolkits to speed adoption • Focused on providing information to prospective DT employers and released in February 2017
• Topics include regulation, scope of practice, hiring and integration, insurance and billing, and successful models, among others. • Information gathering included interview with clinics and providers in MN.
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Employer findings: Excerpt From SIM Grant DT Toolkit, 2016 • Clinics see an economic benefit of hiring DT/ADTs.
• Allows dentists to delegate duties and focus on advanced procedures. • DT/ADTs can be equally as productive as dentists. • Very helpful to fill in when dentists are out.
• Roughly $62,500 is saved annually per ADT employed. • Possible lag in benefits as new hires or new graduates are training. • Most saw adequate production levels after 6 months, comparable to hiring a new dentist.
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MN Dental Therapist Workforce Survey The State of Minnesota collects workforce information on licensed professions on an on-going basis and surveys dental therapists once a year. • The survey focuses on demographics, education, job satisfaction, and future plans. • 63 dental therapists with active licenses as of December 2016 were surveyed January – March 2017 with a response rate of 92%. • The survey data is matched to Minnesota Board of Dentistry data such as birthdate and license status.
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Minnesotaâ&#x20AC;&#x2122;s Oral Health Workforce Dental Therapists <1% Dentists 23%
Dental Assistants 45%
Dental Hygienists 32%
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Education and Employment • Eighty-two percent have a master’s degree. • Ninety-one percent of dental therapists reported they were “working in a paid or unpaid position related to [their] license.” • In 2015, 86% reported they were working. • In 2014, 74% were working.
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Hours Worked • The median work week for dental therapists was 36 hours; this is similar to hours worked in 2015.
Hours Worked in a Typical Week 73%
• 87% reported working a full-time schedule. • More Twin Cities based dental therapists work full-time (96%) compared to Greater Minnesota DTs (80%).
12% 8% 4%
4%
10 or less
11-20
21-30
31-40
41-50
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 52 valid survey responses.
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Primary Work Setting
Setting Solo Private Practice
Share of DTs Working in this Setting 25.5%
Small Group Private Practice (2-4 dentists)
21.6%
Community Based Non-Profit (church, homeless shelter, etc.)
11.8%
Community Health Center/Federally Qualified Health Center Clinic
11.8%
Community/Faith-Based Organization Clinic
11.8%
Large Group Private practice
7.8%
Hospital
3.9%
Academic (Teaching/Research)
3.9%
Long-Term Care Facility
2.0%
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 51 valid survey responses.
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Distribution by Region • Dental therapists location tracks MN population distribution. • For comparison, 54% of the population is located in the Minneapolis-St. Paul metro area. • In 2013, 73% of dental therapists worked in the Twin Cities area.
Minneapolis-Saint Paul
50%
Northeast Minnesota
13%
Southeast Minnesota
11%
Southwest Minnesota
11%
Central Minnesota Northwest Minnesota
9% 7%
Source: MDH Dental Therapist Workforce survey, 2016. Percentages above are based on geocoding of 56 valid Minnesota addresses. To see regions defined, go to https://apps.deed.state.mn.us/assets/lmi/areamap/plan.shtml
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Age of Dental Therapists 70% 64% 60% 50%
40% 30% 19%
20%
14% 10% 3% 0% 34 and younger
35 to 44
45 to 54
55 to 64
Source: Minnesota Board of Dentistry, March 2017. Analysis done by MDH. Percentages are based on all 63 Minnesota licensed dental therapists.
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Future plans to practice as a dental therapist in Minnesota
5 years or less
6 to 10 years
4%
10%
More than 10 years
87%
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 52 valid survey responses.
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Additional Licensure • Dental Therapists can be licensed as a dental hygienist and perform services under both scopes of practice, also called “dually licensed”. Thirty-eight percent of dental therapists are dually licensed. • Ninety percent report spending some time on dental hygiene tasks.
• Fifty-four percent of DTs reported holding an ADT certification, and an additional 18% are in the process of becoming ADTs.
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Dental Therapists with Additional Licensure or Certification
63% 54% 38% 29% 18%
Dually Licensed
Advanced Dental Therapist
Yes
No
In Process
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 56 valid survey responses.
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Best preparation for working in a multidisciplinary team
Informal learning on the job
55%
Formal on-the-job training
9%
Formal educational coursework or training
Continuing education/professional development
34%
2%
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 56 survey responses.
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Best preparation for providing culturally competent care
Informal learning on the job
48%
Formal on-the-job training
11%
Formal educational coursework or training
Continuing education/professional development
None
36%
4%
2%
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 56 survey responses.
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Career Satisfaction 45%
43%
45%
45% In the last 12 months?
4%
Very satisfied
Satisfied
6%
Dissatisfied
6%
Overall?
6%
Very dissatisfied
Source: MDH Dental Therapist Workforce Survey, 2016. The chart is based on 51 responses.
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Dental Therapist Research Stakeholder Group Focus: • Advance knowledge and understanding of dental therapists on oral health outcomes, access, costs, team care, and health services delivery. • Produce common standards for dental therapy research.
• Strategically pursue dental therapy research and improve coordination of studies. • Develop recommendations for changes to improve claims data submission and collection, research, evaluation, reliability and validity of dental therapy studies. • Reduce duplication, and when possible, reduce the burden of research on dental therapists, employers and patients • Partners: Minnesota Department of Human Services, University of Minnesota, Metro State/Normandale, Minnesota Dental Therapy Association, Delta Dental Foundation, Health Partners, Apple Tree, Children’s Dental Services, Minnesota Board of Dentistry 12/13/2017
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Dental Therapist Research Stakeholder Group • Activities: • Collect better billing/claims data from MN state system • Compile list of all MN DT research projects
• Share best practices and lessons learned • Standardize survey questions and data requests • Share research study results and discuss future study efforts
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For More Information • Oral Health Workforce Reports: http://www.health.state.mn.us/divs/orhpc/workforce/oral/index.html • Dental Therapist Toolkit: http://www.health.state.mn.us/divs/orhpc/toolkit.html#dt • Loan Forgiveness Programs: http://www.health.state.mn.us/divs/orhpc/funding/loans/dentalther.html
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A PPLE T REE D ENTAL Access • Compassion • Excellence
In our 32nd year!
Minnesota Centers for Dental Health 130 Community Sites • Low income children and their families • Adults with disabilities • Seniors and elders in longterm care • Urban and rural communities
Total Age Distribution, 2016 34,314 individual patients treated in 2016 98,747 dental visits and screenings provided
13,660
8,415 6,089 3,604 2,477 69
Under 21
21 to 44
45 to 64
65 to 84
85 to 99
Over 100
Whoâ&#x20AC;&#x2122;s on the team?
Oral Health Team Roles Dental Director On-Site Dentists Tele-dentists
Advanced Dental Therapists Dental Therapists
Collaborative Hygienists Nurse Anesthetists Licenced Dental Assistants Lab Technicians Dental Liaisons Care Coordinators Truckers
Metropolitan State University Dental Therapy Class of 2011
Dental Therapy Services 2012-2016 DT/ADT
First Visit
Patients
# Visits
Total Gross
1
Feb 6, 2012
3,847
7,070
$2,202,384
2
Feb 6, 2012
4,956
6,319
$2,112,077
3
Dec 2, 2013
1,951
3,052
$935,931
4
Dec 2, 2013
569
618
$282,006
5
Mar 10, 2014
2,148
3,628
$1,366,726
6
Oct 27, 2014
2,261
2,996
$692,795
7
May 17, 2016
688
812
$195,572
In less than four yearsâ&#x20AC;Ś 16,420 patients safely treated 24,495 dental visits provided $7.8 million in care delivered
PROVIDED FUNDING FOR TWO CASE STUDIES
Dental Therapy Case Studies Heather Luebben, ADT, RDH • On-Site Care at Minnesota Veteran’s Home (1/day per week of full time practice)
Jodi Hager, ADT, RDH • Rural Minnesota at Apple Tree’s Madelia Center for Dental Health
Both employed at Apple Tree as Dental Hygienists prior to and during dental therapy training. Both motivated to do more for their patients and are reaching under-served populations.
Case Study Methods •Analysis of reports from Apple Tree’s Electronic Health Record, Open Dental from 2014-2016 by ADA CDT code •Interviews with dental therapists, dentists, staff, patients and their guardians
LTC Dental Services within Dental Therapy Scope of Practice Heather Luebben, ADT Case Study Subject Only
All DTâ&#x20AC;&#x2122;s and DT Students During Study Period
15%
26% 74%
Maximum Theoretical RDH/DT Minnesota Rules
56 %
29 %
44 % 85%
% Dental Therapist(s)
Maximum Theoretical RDH/DT - CODA Rules
% All Other Providers
71 %
Conclusions - LTC Practice â&#x20AC;˘This case study illustrates that a dental therapist functioning within their scope of practice can serve as a safe, cost-effective, and productive member of an on-site care team. â&#x20AC;˘Findings suggest that other dental programs providing care to this vulnerable population can use this model successfully.
Conclusions - Rural Practice â&#x20AC;˘The ADT is fulfilling the role initially envisioned by the legislation that created the role several years ago to assist in meeting the needs of underserved populations. â&#x20AC;˘The loss of another practitioner accepting public program patients in this rural region is another indication of the importance of this role in this case study.
â&#x20AC;&#x153;Apple Tree was able to increase the frequency of visits. As a result, patients could be seen and treatment completed sooner.â&#x20AC;? LTC Care Coordinator
â&#x20AC;&#x153;The dental therapists increase the number of patients that we can serve. They provide excellent care.â&#x20AC;? Dr. Jayne Cernohous Supervising Dentist
â&#x20AC;&#x153;The ability to dynamically provide restorative care and preventive care is likely an advantageous role for a rural clinic committed to meeting the needs of underserved populations.â&#x20AC;?
Dr. Mark Jurkovich Case Study Consultant
“Well the biggest thing, and it is just like a nurse practitioner, you can make more of them for less money and get them out where they are needed.” Veteran’s Son
Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
CE Credit Available
Contact Information • Laura McLain • laura.mclain@state.mn.us • Deborah Jacobi • djacobi@appletreedental.org • Eamari Bell • eamari.bell@oralhealthamerica.org