DENTAL SAFETY-NET CLINICS

TOP ABSTRACT DENTAL SAFETY-NET CLINICS METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Our study examined dental safety-net clinics, which are dental care providers with a specific interest in providing or mission to provide dental care to low-income and other underserved populations. Although these clinics provide only a small portion of overall dental care (estimated at less than 5 percent^5,6), they may represent an important strategy for improving dental care for groups that face access barriers.

Safety-net dental clinics usually are community-based providers located in low-income areas and serving diverse populations that face various access barriers, often including a limited ability to pay for services. These clinics are sponsored by and/or situated in public health departments, community health centers (CHCs), Indian Health Service clinics and a variety of private not-for-profit service agencies (such as social service agencies), dental schools, dental hygiene programs, school-based clinics and mobile dental vans. No centralized source of data exists for these clinics, and there has been limited study of their operations.

Two of the largest identified groups of dental safety-net clinics include federally subsidized CHCs and those sponsored by local health departments. CHCs are funded to provide primary care medical services and a variety of other health-related services. In 2002, at the national level, it was estimated that 530 CHCs (77 percent of all federally sponsored CHCs) had on-site dental programs (unpublished data provided by J. Anderson, D.M.D., chief dental officer, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, Md., September 2003) and between 10 and about 30 percent of all local public health departments provided some oral health care services.^1,7,8

Two of the largest identified groups of dental safety-net clinics include federally subsidized community health centers and those sponsored by local health departments.

Previous studies have suggested that these clinics have limited resources and only modest capacity to provide dental services.^9–12 However, there have been calls to expand the dental safety-net clinics to reach more of the target population. For example, the national public health agenda, Healthy People 2010, has established a goal of increasing the proportion of CHCs and local health departments that provide dental care by 2010.⁷ The Bush administration has set a goal of increasing the number and scale of CHCs to reach larger numbers of the target population.¹³ In 2003, a portion of federal CHC funding ($32 million) was pledged to fund new or expanded oral health care services in CHCs (unpublished data provided by J. Anderson, D.M.D., September 2003). States have offered financial support to expand the capacity of these clinics.¹⁴

To help those who are concerned about the dental access problem better understand the role of safety-net dental clinics, we designed a study in Illinois to assess their dental capacity, types of patients served and other characteristics. This study builds on previous assessments of the dental work force and access to dental care in Illinois.^6,15 These studies showed that the supply and distribution of dentists in the state follow many national patterns.

In 2000, about 6,900 active patient care dentists served a population of 12.1 million residents (59 dentists per 100,000 population).¹⁶ A lower dentist-to-population ratio was found in rural Illinois counties (32 dentists per 100,000), and a higher supply ratio was found in Cook County (65 dentists per 100,000 population), which includes Chicago. However, the supply of new Illinois dental graduates dropped dramatically during the 1990s, from 315 graduates per year in 1990¹⁷ to slightly more than 100 in 2002¹⁸ owing to the closure of two private dental schools and cutbacks in class size in the largest state public university dental school.

Illinois has considerable dental access problems. Nationally, about 26 percent of dentists treated patients insured by Medicaid in 2000,¹⁹ and in Illinois, a similar percentage of dentists (25 percent) billed Medicaid for services in 2000.⁶ Only about one-third of Illinois children who were covered by Medicaid or the State Children’s Health Insurance Program (SCHIP) had a dental visit in 2000.⁶ In 2001, 80 percent of Illinois counties were fully or partially designated as dental health professional shortage areas.²⁰ A sizable proportion of Illinois residents younger than 65 years had financial risk factors for low utilization of care: about 32 percent had family incomes of less than 200 percent of poverty levels, 16 percent lacked health insurance and 11 percent were publicly insured.²¹

Building on our overall experience with previous state-level dental studies,^{14–16,22–24} we designed this study to provide a systematic examination of safety-net dental clinics in Illinois and to address several questions. How are these clinics organized, operated and financed? Do they provide dental care services to the targeted population groups (low income and other underserved people)? How do these clinics relate to dentists and other dental facilities and programs in their communities? What is their capacity for care and what factors limit their productivity? We then examined ways these clinics might assist dentists and others who are addressing dental access challenges.

	METHODS

TOP ABSTRACT DENTAL SAFETY-NET CLINICS METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
We designed this study to include all safety-net dental clinics in the state, as identified by the Illinois Department of Public Health (IDPH) Division of Oral Health, which maintains an updated list of clinics. The list included CHCs, city and county health departments, private not-for-profit agency clinics, clinics associated with schools of dentistry or dental hygiene education programs, school-based clinics, hospital-based dental clinics and others.

To ensure dental input and representation in the study, we formed an advisory group composed of representatives from the state dental society, the state public health department, the state primary care association, a statewide public-private dental coalition, and other oral health care professionals and policy makers. This group provided input at several steps in the process, including reviewing the list of clinics, assisting in the development of the survey, and reviewing the study findings and conclusions.

We conducted the survey using a confidential, written questionnaire that consisted of 44 questions organized into the following six sections:

– dental clinic profile;

– dental visits;

– referrals to outside dentists;

– clinic staffing;

– funding sources and budgets;

– future needs.²⁴

The institutional review board of the University of Illinois at Chicago approved the study.

In June 2001, we mailed surveys to all 94 clinics on the IDPH list. We considered each clinic to be a separate respondent, although a single organization may have sponsored more than one clinic. Surveys were mailed to the executive/administrative director or dental director at each clinic. We sent a reminder postcard a few weeks after the initial mailing. In August 2001, we mailed a second survey. To further improve the response rate, advisory group members contacted colleagues, and research staff members telephoned nonrespondents.

We received responses from 71 clinics, for a 76 percent response rate. Fifty-two organizations sponsored these clinics, with a range of one to eight clinics per sponsor. The 71 responding clinics were located in 26 of Illinois’ 102 counties. The largest number of respondents (37) were located in Cook County (which includes Chicago), followed by other urban counties (21 clinics in 14 counties) and rural counties (13 clinics in 11 counties). Respondents included 23 CHCs, 21 local (city or county) health departments, 13 private not-for-profit service agency clinics, seven clinics associated with dental hygiene programs, two dental school clinics, two school-based clinics and three others. The nonrespondents included all types of clinics and were distributed geographically throughout the state.

Our descriptive analysis focused on the 57 clinics representing the three largest identified groups of community-based clinics: health centers, health departments and private not-for-profit clinics.

Our research assistant entered survey responses into an electronic spreadsheet database, and one of us (G.R.B.) conducted the analyses using statistical software (SAS Institute, Cary, N.C).²⁵ We conducted simple descriptive analyses to estimate the annual dental visit capacity according to various categorical groups, such as clinic sponsorship, dental staffing pattern, hours open per year (assuming a 50-week year) and the number of dental operatories. We present descriptive statistics for key response variables.

The survey asked clinics to report the number of personnel by paid and volunteer (that is, unpaid) status and by full-time and part-time status, but not by staff hours worked. Thus, we did not estimate full-time equivalent staffing, and staffing information is presented according to categories of staffing. We present dental visits as the total number of visits provided in calendar year 2000. We asked clinics to report the number of hours the facility was open per week, and we assumed a 50-week year for certain derived measures.

The survey asked clinics to provide limited financial data, including all sources of funding and other resources, the percentage of total revenue from patient fees and the percentage of patient fee income from various insurance programs and out-of-pocket payments. We also asked clinics to report their year 2000 annual dental clinic budget according to one of eight levels, beginning at less than $50,000 and increasing by $50,000 increments to $400,000 or over.

	RESULTS

TOP ABSTRACT DENTAL SAFETY-NET CLINICS METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Clinic operations. The dental clinics had been open for a mean of 16 years and a median of 12 years (range, less than one year to 86 years) (Table 1). Eighty percent of the dental clinics operated at sites that also provided other health care services (91 percent of health centers, 70 percent of health departments and 77 percent of private agencies). The number of dental operatories/chairs per clinic ranged from one to 12, with a mean of 2.7 chairs; 80 percent of clinics had three or fewer chairs.

Patients and services. Most dental clinics reported serving children and adults, with many clinics serving Medicaid-enrolled and uninsured people. About two-thirds of clinics served people with HIV/AIDS and about 80 percent served people with disabilities. Almost all clinics reported providing at least some level of preventive, diagnostic and basic restorative services (Table 1). On average, clinics provided more than 3,100 dental visits during the previous calendar year (2000), although the range of visits provided varied substantially (from 300 to 18,440 visits). Health centers provided more visits and had more capacity and resources (hours of operation per week, dental staffing, number of dental chairs) than did other clinics. Appointments averaged 33 minutes for all clinics, and the length varied slightly across clinic types.

Clinics also reported providing a variety of outreach and educational oral health services, including dental screenings, health fairs, sealant programs in schools, public education and oral health awareness programs, to many groups (such as schools, nursing homes, community meetings), as well as peer education training, media education, local advertising and tobacco-use cessation programs. A greater proportion (90 percent) of health department clinics conducted outreach programs than did health centers (70 percent) or private agencies (77 percent); in addition, among those clinics offering outreach programs, health departments provided, on average, more programs annually (29 programs) than did health centers (10) or private agencies (six).

Dental referrals. The survey also asked respondents whether they were able to provide all of the dental services needed by their clients; only 12 percent of clinics reported that they could. About 80 percent of clinics referred patients to private dentists if additional dental care was needed, with clinics reporting that four to six private dentists in their area accepted their referrals. The survey did not collect data regarding the number of, or reasons for, patient referrals to private dentists. Table 1 shows the percentage of clinics that referred patients to private dentists, dental schools, other safety-net dental clinics and hospital emergency departments. In general, clinics reported that it was difficult to refer uninsured adults and children, but somewhat less difficult to refer patients covered by Medicaid. Private agencies reported experiencing less difficulty in referring all types of patients.

Missed appointments. Missed appointments were a common problem, with an average of 24 percent of all appointments missed each week. Table 1 shows the percentage of appointments missed for CHCs, health departments and private agencies. The most common procedures for handling missed appointments were overbooking patients and establishing policies that restricted patients’ future use of services. A small number of clinics reported using penalty fees, reminder letters or telephone calls, or they replaced broken appointment times with walk-in or standby appointments.

Clinic finances. Across all clinic categories, about one-fourth had annual budgets of less than $100,000 and two-thirds had budgets of less than $200,000; only two clinics reported an annual budget of more than $400,000. Sources of revenue and other support included patient fees and insurance; grants (including federal grants); state, county or school board funding; private contributions; donated dental equipment and supplies; and volunteer time from dental professionals. On average, patient fees made up only about one-third of all revenue, and this varied from about one-fourth of all revenue for private agencies to about one-half of all revenue for health centers (Table 1).

Dentist staffing levels. Table 2 shows the staffing arrangements for the 57 clinics. All clinics had dentists on staff, as required by the Illinois Dental Practice Act. About two-thirds of the clinics had full-time dentists (usually one dentist), about one-fourth had part-time dentists (on average, three dentists) and four clinics had only volunteer dentists. Private agencies were more likely to have part-time and volunteer dentists; only 39 percent employed any full-time dentists. Across all 57 clinics, 124 paid dentists and 78 volunteer dentists (data not shown) worked full time or part time. If one assumes that no dentists worked or volunteered at more than one clinic, a total of 202 dentists provided care in these 57 clinics across the state.

Dental staff recruitment. The most common resources used to recruit dental professionals were local advertising and affiliations with dental schools or dental hygiene programs. Health departments also recruited through local dental associations and dental hygiene associations, the Internet and the federal National Health Services Corps program. Low wages and salaries and relatively small benefits packages presented a challenge for clinics in their recruitment efforts. Other challenges were a need for bilingual staff members, finding qualified staff members, finding employees who bought into the mission/philosophy of the clinic and the clinic’s location (for example, recruiting dental professionals to rural communities, small towns).

The survey asked respondents, "What would make recruitment of qualified staff easier?" They reported that they felt recruitment could be improved with the ability to provide better pay and by adding or expanding employment benefits. Other responses included increased clinic funding; more training programs for dental assistants; greater certainty about the loan repayment programs; a larger pool of dental graduates (for example, one respondent reported that "closing of dental schools has impacted our agency"); greater levels of volunteerism from dentists and dental societies; and assistance with the recruitment process, such as a regional or state database of available jobs, collaborative recruitment with federal, state and/or local governments and the active involvement of dental societies.

Impact of staffing on dental visits. Table 3 shows the relationship between dental staffing and annual clinic visit productivity. Measures of capacity (staffing level, number of operatories and clinic hours) related to each other. In other words, clinics with full-time dentists also had one more dental chair and were open about 15 more hours per week than were clinics with only part-time or volunteer dentists. Data limits do not allow us to separate the independent effects of staffing levels. However, we can make some general observations. First, clinics with full-time dentists provided more dental visits than did those with only part-time or volunteer dentists. Further analysis of the clinics with only volunteer dentists (that is, the private agency clinics) revealed that these clinics provided relatively few visits per dentist (26 to 111 annual visits per dentist).

	DISCUSSION

TOP ABSTRACT DENTAL SAFETY-NET CLINICS METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
These dental safety-net clinics address dental access problems and barriers in several ways. These clinics are distributed throughout the state, in urban and rural locations. They have served their communities for many years and maintain adequate hours of operation. Clinics reported that they provided the most common dental services, and when additional services were needed, they could refer patients to dentists in private practice, dental school clinics and other dental clinics.

The clinics treated low-income patients who were either uninsured or covered by public insurance programs (Medicaid or SCHIP); only 1 percent of their revenue came from private dental insurance. The clinics also reported treating people with personal access problems, such as those with HIV/AIDS, the homeless, migrant farm workers, children who were wards of the state and people with disabilities. Some clinics provided access for rural populations, which often have problems finding dentists owing to the smaller numbers of practitioners in rural areas.^15,26–29

Because most of the safety-net dental clinics were located within facilities that provided other health care services, patients might perceive them as being more accessible and familiar. These facilities often had additional resources (such as social services, language translators, transportation assistance) and could offer other benefits and efficiencies of "one-stop shopping" for patients and their families. This assistance and familiarity reduce important nonfinancial access barriers. The dental clinics offered a variety of oral health outreach and educational programs designed to reach broader groups and expand the oral health message, possibly preventing further dental problems.

Capacity of safety-net dental clinics. The safety-net dental clinics represent only a small component of overall dental care in Illinois. Using the results of a 1999/2000 study, we estimated that Illinois safety-net dental clinics accounted for less than 2 percent (about 300,000) of all dental visits in the state.⁶ Gehshan and Straw⁵ also reported that only a small percentage of overall dental care is provided through these types of clinics. However, these clinics provide a larger proportion of care for the targeted population, namely people who face barriers to accessing dental care. We need to know more about the capacity and productivity of these clinics and their relationships with dentists in private practice.

Few dentists are employed by, or report an intention to pursue employment in, safety-net dental clinics.^30,31 If we extrapolate the findings from our analysis of the 57 clinics to estimate dentist participation or employment for all 94 clinics in the state, we could arrive at a rough estimate of the number of Illinois dentists practicing in some capacity in the state’s safety-net dental clinics. Applying the estimate of 202 un-duplicated dentists at 57 clinics to the 94 total clinics yields an estimate of 333 dentists, or about 4.8 percent of all active dentists who provide patient care in Illinois (333 of 6,900 dentists). Many of these dentists work on a part-time or volunteer basis, so the 2 percent estimate stated above likely is reasonable.

The capacity and productivity of dental safety-net clinics could be increased in several ways. Our findings show substantial differences in the number of annual visits based on staffing patterns, hours open and number of operatories (all interrelated factors). It appears that, given appropriate facilities (including sufficient numbers of dental chairs), using full-time paid dentists and dental hygienists would increase clinic productivity.

According to the ADA Survey Center,³⁰ 71 percent of general practitioners in private practice employed a dental hygienist in 1998 (and reported more annual patient visits than did those who did not employ a hygienist); by comparison, only 35 percent of clinics in our study employed a dental hygienist. Thus, our finding of increased dental visit capacity with dental hygienists on staff is consistent with the results of the ADA study of private practitioners. Further study of the relationship between safety-net dental clinic staffing and productivity would contribute valuable information to federal and state programs that place dentists in underserved areas.

Another finding that merits further study involves the productivity of clinics relying on volunteer dentists. Clinics that used only volunteer dentists or a combination of volunteer and part-time paid dentists had fewer annual visits than did other clinics. Dentists and those in leadership positions have strongly encouraged, and should continue to encourage, dentist volunteerism. However, future studies could examine whether the lower volume of visits simply reflects fewer dentist hours or reflects other factors that could be addressed to improve clinic productivity. While our study could not assess other factors that affect clinic efficiency and productivity, we should note that efforts by federal agencies are under way to offer assistance to community-based clinics to improve their overall efficiency and productivity in areas such as management, patient flow and information systems.³²

Study limitations. Several design features limited our study, notably the sample drawn from a single state. Although the high response rate, diversity of clinics and questionnaire design provided rich descriptive data, more sophisticated analyses (such as examining independent contributions of staffing levels or clinic hours) could not be conducted owing to the small sample size and limited level of detail for several variables. For example, it would have been useful to ask respondents for the number of specific dental procedures performed in each clinic and the hours worked by each dental staff member or volunteer.

A more complete picture of dental safety-net clinics requires the direct input and perspective of dentists, other health care providers and the target population. We believe that this information can best be gathered through interviews or focus groups that could explore themes and topics in more depth than can be done with written surveys. However, considering the dearth of data on dental safety-net clinics, our study adds to the overall knowledge of the system and provides baseline data, as well as a methodology and survey instrument for use in studies by other states or in a longitudinal study in Illinois.

	CONCLUSION

TOP ABSTRACT DENTAL SAFETY-NET CLINICS METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Addressing the challenging problem of access to dental care requires support from many sectors, as well as a multifaceted strategy. The safety-net dental clinic system, although small, is an important component that should be preserved, because it provides access to oral health care for low-income and other vulnerable populations. Therefore, support for and expansion of the dental components of safety-net and other community clinics should continue.

Our study identified a straightforward approach to assess these clinics that can be used readily by other states. We also identified key areas (such as dental staffing, location at sites that provide other health care services) that could be examined for their potential to contribute to greater productivity. Further study of other types of clinics (such as dental school clinics) and more system-wide issues would allow dental policy makers and planners to gain a better understanding of this vital component of the overall dental care delivery system.