Bill Piskorowski, DDS Associate Dean for Community-Based Clinical Education UCLA School of Dentistry [email protected]Clinical Associate Professor Emeritus of Dentistry University of Michigan School of Dentistry [email protected]Mark Fitzgerald, DDS MS Associate Dean for Community-Based Collaborative Care & Education (Effective 9/1/2017) University of Michigan School of Dentistry [email protected]Howard Hamerink, DDS Associate Director of Community-Based Clinical Education) University of Michigan School of Dentistry [email protected]
Transcript
Bill Piskorowski, DDSAssociate Dean for Community-Based Clinical EducationUCLA School of [email protected]
Clinical Associate Professor Emeritus of DentistryUniversity of Michigan School of [email protected]
Mark Fitzgerald, DDS MSAssociate Dean for Community-Based Collaborative Care & Education (Effective 9/1/2017)University of Michigan School of [email protected]
Howard Hamerink, DDSAssociate Director of Community-Based Clinical Education)University of Michigan School of [email protected]
Solving Access to Care, It’s Like Eating an Elephant
Access to oral health care can be enhanced by increasing and redistributing providers. To solve this problem, 3437 providers could be added to community clinics in three years
The vision is to implement and disseminate a template that includes accountability through a secure cloud–based assessment tool and virtual mentorship through telehealth to enhance both patient outcomes and student clinical education.
Expanding access to care for low-income populations in three categorical ways:
Structurally improve access by providing care in existing shortage areas through affiliations with Dental Schools,
Culturally improve delivery by transforming attitudes about care to Medicaid patients and vulnerable populations.
Sustainably, using a revenue sharing model to improve access through recruitment and retention of future dentists to serve low-income patients, by exposing future dentists to communities in need, and increasing the proficiency of new dentists and clinic operations by using new technologies and telehealth/telementoring systems
The Process:
Creating an Optimal Clinical Environment wherever there is need Determining your needs – what educational outcomes do you want? Selecting sites to meet your needs Contracts and financial sustainability Preparing the sites
Making the most of the educational opportunity Tracking and assessing student performance Monitoring sites for quality Enhancing student experience through assessment and verifying student
competency
Results, Challenges and Future Directions Telehealth / Telemedicine will be the future of professional growth and
accountability. The value of Virtual mentorship Describing a new dental model
New technologies
Evidence-based dentistry
social diversity
medically compromised patients
special needs
existing curriculum
We all have our challenges but challenges create opportunity
Mission Statement: Enhancing Our Student’s Education while increasing access
to care for vulnerable populations through Community Service.
UCLA Strategic Plan for Community-based Clinical Education (CBCE) development
Community-Based Experiences and CODA
CODA Standards State:
2-25 Dental education programs must make available opportunities and encourage students to engage in service learning experiences and/or community-based learning experiences.
Contributions Outreach Program Can Make to Accreditation
Provide external assessment of student skill development and competency
Provide expanded experience opportunities for student clinical skill development Access to special needs patients (CMS and IOM guidelines) Access to diverse patient populations and procedures that may
be limited at the school
Both were stated commendations by site visitors at exit interviews in a recent CODA Accreditation Site Visit
Cloud Based Assessment of Community-Based Dental Education (CBDE) Activity Has Demonstrated Compliance With CODA Standards: Exposure to an appropriate distribution of the
following:
Exposure to Special Needs
Treating Diverse Populations
Types and Complexities of Patient Services
Exposure to all age groups
Understanding Reimbursement Models
Creating an optimal Clinical environment for a student service learning program
BACKGROUND: Medicaid Dental Benefits Started in the early 1970s Access to Care for both children and adults covered by this healthcare
program has ALWAYS presented significant challenges
Access problems due to 3 factors: Difficulty (perceived) in complying with arduous claims submission
procedures Low reimbursement rates (<45% of Usual Customary Rate) Very narrow spectrum of covered services for adults
Implementation
The opportunity parallels School’s of Dentistry’s Philosophies and Strategic Plan
Understanding, prioritizing and being respectful to the internal and external challenges
Capitalizing available resources
Utilizing templates that already exist
Malcolm Baldrige Award( Presidential award for performance excellence)
2011-2012 Education Criteria for Performance Excellence
Baldrige Excellence Builder
How It Started:The State of Michigan provided $10 million in 1999 for
a 3-pronged attack to address the chronic access problem for dentally underserved population
The money was allocated to:1. Provide funds to community clinics to establish or expand dental clinics
throughout the state
2. Establish the Healthy Kids Dental Program in 37 counties where community clinics do not exist
3. Provide start-up funds to establish the University of Michigan School of Dentistry Community Outreach Service Learning Program
Detroit
Bad Axe
Bay Cliff
Ann Arbor
Traverse City- Donated Dental Service Program
Detroit
Bad Axe
Bay Cliff
Ann Arbor
Baldwin
White Cloud
Grant
Grand Rapids
Flint
Atlanta
Saginaw
Muskegon
Oscoda
Taylor
Traverse City- Donated Dental Service Program- Federally Qualified Health Center
Detroit
Brighton
Bad Axe
Bay Cliff
Mt. Pleasant
St. Johns
Hart
East Jordan
HarborSprings
GaylordMancelona
Ann Arbor
Port Huron
Monroe
Baldwin
White Cloud
Grant
Grand Rapids
Flint
Atlanta
Saginaw
Muskegon
Oscoda
Taylor
Traverse City
Harrison
- Donated Dental Service Program- Federally Qualified Health Center
- Community Dental Health Clinic
Detroit
Brighton
Brimley
Peshawbestown
Bad Axe
Bay Cliff
Mt. Pleasant
St. Johns
Hart
East Jordan
HarborSprings
GaylordMancelona
Ann Arbor
Port Huron
Monroe
Baldwin
White Cloud
Grant
Grand Rapids
Flint
Atlanta
Saginaw
Muskegon
Oscoda
Taylor
Traverse City
Harrison
- Donated Dental Service Program- Federally Qualified Health Center
- Community Dental Health Clinic
- Indian Health Service /Tribal
Detroit
BrightonPlymouth
Brimley
Peshawbestown
Bad Axe
Bay Cliff
Mt. Pleasant
St. Johns
Hart
East Jordan
HarborSprings
GaylordMancelona
Ann Arbor
Port Huron
Monroe
Baldwin
White Cloud
Grant
Grand Rapids
Flint
Atlanta
Saginaw
Muskegon
Oscoda
Taylor
Traverse City
Harrison
- Donated Dental Service Program- Federally Qualified Health Center
- Community Dental Health Clinic
- Indian Health Service /Tribal- Private Practice
Detroit
BrightonPlymouth
x
Brimleyx
Peshawbestown
Bad Axe
Bay Cliff
Mt. Pleasantx
St. Johnsx
Hartx
East Jordanx
HarborSprings
GaylordMancelona
Ann Arbor
Port Huronx
Monroe x
BaldwinxWhite CloudxGrantx
Grand Rapids
xFlint
Atlanta
Saginaw
Muskegon
Oscoda x
Taylor
Traverse City
Benton Harbor
Battle Creek
- Donated Dental Service Program- Federally Qualified Health Center
- Community Dental Health Clinic
- Indian Health Service- Private Practice
-WPP
x
#
#
#
##
# #
#
#
Expansion Efforts
#
#
Kalalmazoo
Why not explore opportunities to share sites with other dental schools?
• Tracking and assessing student performance
• Monitoring sites for quality• Opportunities for enhancing student
experience and verifying student competency
Evaluating the educational opportunity
Strategies for Assessment Traditional strategies used to measure student’s
learning in DDS program
Internally: Example - School’s measures of academicperformance
Externally: Example - Student’s performance on national exams and regional or statelicensing exams
Assessment:CBDE is a Capstone Assessment
Clinical competency is difficult to measure in a traditional academic setting
The Outreach – Curriculum connection is critical in evaluating student’s growth as a practitioner Multiple valid assessments in immersion clinical
practice settings (outreach) can help in measuring clinical competency
Gets at the “do you trust this student as a practitioner”
Strategies for Outcomes Assessment“plan -> implement change -> assess ->improve”
External measurement by Outreach Clinic Faculty Adjunct faculty members at our outreach clinics provide the
administrative unit for CBDE with regular feedback regarding the performance of our D4 students in providing patient care at these clinics.
Program has added a new and important source of external feedback on student performance to our outcomes assessment program. “New set of eyes and ears” for our outcomes assessment process. High quality external feedback about the D4 student performance Provides useful information about the extent to which our
curriculum prepares students to treat patients in these settings.
Assessment of Skill Development and Competency
CBDE Student Performance Criteria linked to UM SOD 2014 Competencies in the 13 point scale*1. Follows clinic protocols
• UM Competencies 1, 3 • CODA 2-17,20
2. Analysis of Dental/Med Histories • UM Competency 8 • CODA 2-23a, 15
3. Knowledge of prescribing oral meds • UM Competency 8 • CODA 2-15, 23a
11. Level of independence• UM Competency 2 • CODA 2- 10, 20
12. Ability to self-evaluate (realize own strengths and weaknesses) • UM Competencies 2,7 • CODA 2-10, 14, 15, 18, 20, 21
13. Interaction with staff and dentists • UM Competency 6 • CODA 2-15, 19, 23g
*Peer-reviewed scholarship validated for assessment of student’s clinical competenceJ Dent Ed 2016, 80(10):1237-44
Annual summaries of performance ratingsand the response by the dental school
• Thresholds for action for individual students and the program:• Individual students
Any student receiving a rating in the “needs improvement” range (1/2) is counseled by the outreach director and/or other appropriate person. Benchmark for individual students is no rating < 3.
• CurriculumIf total student ratings in any of the assessed areas reaches or exceeds 5%, then a program evaluation is conducted and appropriate corrective action is taken. Benchmark for the program is < 5% total (1/2) ratings in any single performance area.
Outreach - Student Performance Data 2006-20071. Follows clinic protocols2. Analysis of Dental/Med
4 hours volunteered for every $100 worth of services received
(C2 Program)
VolunteerServices
Outcomes of Dental Access Program (DAP)
The University of Michigan DAP Clinic. revenues generated included 26 sessions from Feb 2011 – Apr 2014,
Approximate Value=$433,000
The Volunteer Dentists from 2007-2014 generated approximately $750,000.00 in service
PA-161 hygiene services at Garfield generated $117,945
Approximately 1200 unique patients were treated and thousands of hours of community service were completed by those receiving care
Mission: Enhancing student education while providing care to disabled and homeless military veterans.
Improve oral health care for disabled and homeless veterans
Create a model that could be used in other communities throughout Michigan
Enhance the dental students education through clinical experience
Expected Outcomes
ResultsUniversity of Michigan SOD Expenses $23,276
Total Production $123,563
Return on Investment 531%
42
Changing the lives of 45 veterans - Priceless
Results:
Expenses $52,380.30
Total Production $372,884.00
Return on Investment 711%
43
2 Veteran Program Results
83 patients served to completion
$75,656.30 dollars of hard costs
$496,447.00 dollars COMPREHENSIVE service
656% return on resources obtained
You cannot describe the heartfelt gratitude that all witnessed
Changing the lives of 83 veterans - Priceless
VA 28from Roscommon, 9+ clinic visits
Before Treatment After Treatment
VA 15from Alpena, 5+ clinic visits
Before Treatment After Treatment
VA 259 clinic visits
Before Treatment After Treatment
Recognitions
2013 – Ida Gray Award University of Michigan Multicultural Affairs Committee
2013 –Annual James T. Neubacher Award University of Michigan’s Council for Disability Concerns
2014 – Certificate of Recognition, 2014 Forever Go Blue Award University of Michigan Student Philanthropy Team.
2013 Oral Health Care Project for Veterans Wins National Award
Student-Led Wolverine Patriot Project Wins American Dental Association Foundation Annual Bud Tarrson Dental School Student Community Leadership Award
Design For Sustainability Expand the veterans service model within the present CBDE
community of clinics throughout Northern MI
Disseminate information to Dentists regarding treatment of veterans based on today’s Governmental policies
Assure payment for services provided to qualified veterans from VA programs when possible.
Make this initiative a referral program from CBOC (Community-Based Outreach Clinic)
How many have heard about the VADIP program?
49
Otsego and Surrounding Counties Antrim, Charlevoix, Cheboygan, Crawford, Emmet,
Kalkaska, Montmorency, Oscoda, Otsego
Between these counties, there are only 18,745 veterans
Of those veterans only 3,886 (20.7%) receive V.A. benefits
Expansion
51
Victor’s Open Arms-Vista Maria
Helping the young women of Vista Maria (Human Trafficking Victims)
Results, Challenges and Future Directions
“Academic Connection” (CBDE)Those organizations and programs
(including us) that have embraced the Academic Connection have noticed more
productive and predictable results
Impact on Curriculum:Pre and post rotation evaluations
Influence of Community-Based Dental Education on Dental Students’ Preparation and Intent to Treat
Underserved Populations Wilhelm A. Piskorowski, D.D.S.; Stephen J. Stefanac, D.D.S., M.S.; Mark Fitzgerald, D.D.S., M.S.; Thomas G. Green, Ph.D.; Rachel E. Krell, B.A.
Journal of Dental Education, Volume 76, Number 5/May 2012
Table 3. Comparison of student’s confidence level in treating underserved patients before and after community rotations in 2009
Survey Response Before Rotation After Rotation Change
Very high 8.6% 24.6% +16%High 43.1% 57.9% +14.8%Average 44.8% 17.5% -27.3%Low 3.4% 0% -3.4
Pearson chi-square test: p=0.002
Community-based clinics as student first career choice compared to the number of weeks spent in outreach
An IPE/IPC model designed to improve patient care, organizational efficiency and learning.
Integrating IPE and Collaborative Practice into Everyday Patient Care
Michigan Oral Health Workforce Expansion and Enrichment Project
Michigan Department of Community Health (MDCH)HRSA Award #: 1 T12HP26283-01-00
Mark Fitzgerald, DDS, MSHoward Hamerink, DDSBill Piskorowski, DDS
CODA Standard: Graduates must be competent in communicating and collaborating with other members of the health care team to facilitate the provision of health care.
Interprofessional education (IPE)
Patient Centered
care
www.richmondinstitute.com
DentistryNursing
PharmacySocial workMedicine
Physical therapy
OutcomesInterprofessional Collaborative Care (IPC): Can be successfully implemented in a dental setting Improves overall patient care efficiency and efficacy Improves patient flow in the FQHC Reduces patient visits for overall health care
Is embraced by student participants, clinic staff and administration
Is readily accepted by patients in a FQHC setting
Is a financially stable model
Is flexible enough to be used in different settings with different student populations
NameTitle
UCLA Community-based Dental Education
“Developing an Enhanced Model for
Collaborative Care”
22 sites
Under Review
Community-Based Clinical Education (CBCE) SITES
It all starts here!
What we do know after more than one decade of service:
• Students will gravity to clinic opportunities that are well managed.
• Students select post graduate opportunities based on mentorship and growth opportunities
• Students prefer 3 (12 hour) work weeks, followed by 4 (10 hour) followed by 5 (8 hour) work weeks as their last choice
• With that said, our next frontier involves virtual mentorship in a secured cloud-based system.
Telehealth and Mentoring Housed in a Cloud-Based System is
Imperative for future clinical collaboration:
Systems exist that enables detailed telehealth services as well as instructional and mentoring services for professionals,
regardless of geography, to be provided at any time with great ease.
CBDE Program Strengths
Strong partnerships
Community involvement
Constant evaluation and reassessment of student activities along with clinic and preceptor performance
Significant amounts of treatment delivered
The sites with the best orientations are the most valued and productive
Positive student outcomes as measured by faculty and preceptor student evaluations
Win-Win Outcomes Win for the underserved communities (public) who
experienced increased access to care Win for the centers (policy) -increased and more consistent
productivity of Federal, State and Community funds and programs
Win for the students (philosophy) who enhanced their clinical skills and broadened their experience base to include an ethic of caring
Win for the school (procedures) in the form of predictable and full coverage of all program costs
Win for sites (philanthropy) for they have noted a significant increase in recruitment of recent graduates as practitioners and interest in donated services thus helping to solve a chronic manpower problem
Being Responsive The community outreach endeavors are not static
because we are always looking for the “best model”. We always try to remember two important points. First, since oral health care is a dynamic profession,
nothing remains “as is” for very long. We have to: Continue to be responsive. Do our best to adapt to the needs of our community
partners who, in turn, are doing their best to respond to the needs of patients and to our student’s education.
Remember that our flexibility and actions convey an important message to our students: they too will have to be adaptable as practitioners.
Bill Piskorowski, DDSAssociate Dean for Community-Based Clinical EducationUCLA School of [email protected]
Clinical Associate Professor Emeritus of DentistryUniversity of Michigan School of [email protected]
Mark Fitzgerald, DDS MSAssociate Dean for Community-Based Collaborative Care & Education (Effective 9/1/2017)University of Michigan School of [email protected]
Howard Hamerink, DDSAssociate Director of Community-Based Clinical Education)University of Michigan School of [email protected]
