Midlevel Provider Models*Ben Youel, UIC ASDA PresidentFriday, January 13th, 2012

*Adapted from presentation given in October

2011 at ASDA Central Regional Meeting

What are we going to cover?

• Four Models• A Spectrum:

• Community Dental Health Coordinator • Dental Therapist (MN)

• Advanced Dental Therapist (MN)• Dental Health Aid Therapist (AL)• Advanced Dental Hygiene Practitioner

Dental Health Aid Therapist Dusty PfundhellerDistrict 5 Trustee

What is a DHAT?

• “Dental Health Aid Therapist”• dependent practitioner working in a satellite clinic under the

general supervision by an off-site licensed dentist located at a distant regional clinic

How Were DHAT’s Created?• Alaska

• May 2000 – Oral Health in America: A Report of the Surgeon General• Alaska Native Tribal Health Consortium (ANTHC)• 85,000 Alaska Native people live in rural Alaska with no road access. • 5 times caries risk in children • Alaska allowed high school graduates go to New Zealand for a two

year program (2003 – 2005)• 2004 – First DHATs began practicing• In 2007 ANTHC partnered up w/ Kellogg Foundation to study at

University of Washington’s Medical School - 1 year is pre-clinical, 1 year clinical.

Training for DHAT

• 2 yr program• Must have high school diploma or equivalent & 6wk

online anatomy & physiology course• 1st year = pre-clinical work & classroom setting• 2nd year = clinical experience, village practice rotations• 400 clinic hours (six-month) residency program• Every two years DHATs must be recertified.

• 24 CE credits• Demonstration of ongoing clinical competency

Scope of practice

• Determined by the supervising dentist during the residency based on DHAT’s demonstrated clinical skills and tribal location needs• Determines of clinical procedures and scope of practice

• Dynamic – may change periodically depending upon the maturing skills-set of the therapist.

• Typical DHAT may provide oral exams, preventive dental services, simple restorations, stainless steel crowns, extractions and take x-rays.

Supervision

• General supervision by an off-site licensed dentist located at a distant regional clinic.

Community Dental Health CoordinatorsTrent LallyDistrict 6 Trustee

What is a CDHC?

• “Community Dental Health Coordinator” or “CDHC”• Part of an ADA comprehensive effort to improve access to oral

health care for underserved Americans.• Promises to help Americans become better stewards of their oral

health.

Is the CDHC a “mid-level provider?”

• No. Mid-level providers are being promoted to drill, fill, and extract.

• CDHC focuses on the root causes of disease – the lack of adequate prevention and oral health literacy among populations.

Background

• To help expand access to the same high quality dental care available to all Americans, the ADA is helping to develop a new member of the oral health team.

• National Coordinating and Developing Committee (NCDC) was established to create a CDHC training program.

• March 2009 – Pilots launched

How will the CDHC improve Access?

• Assist the dentist in the triage of patients• Address social, environment and health literacy• Educate community members• Part of a comprehensive approach that also includes:

• Improving Medicaid reimbursement rates• Placing new focus on oral health education and prevention• Increasing government investments in the public health

infrastructure

• Students in the CDHC pilot program are recruited from the communities in which they serve.

How are CDHC’s trained?

• Pilot Programs• 18-month training program (12 months didactic + 6

months internship)• University of Oklahoma• Temple University• A.T. Still University Arizona School of Dentistry

What is the CDHC scope?

• Collect information (photographs, radiographs)• Screenings• Fluoride treatments• Sealants• Temporary filings• Simple teeth cleanings (gingivitis) until a patient can

have a comprehensive cleaning

Where do CDHC’s work?

• Clinics• Schools• Churches• Senior Citizen Centers• Other public settings

Update

• New Mexico first state to authorize CDHC model

Advanced Dental Hygiene Practitioner (ADHP)Burton ColemanASDA District 4 Trustee

What is it?

• Advanced Dental Hygiene Practitioner• American Dental Hygiene Association (ADHA)

proposed position in 2004A dental hygienist who has graduated from an

accredited dental hygiene program and has completed an advanced educational curriculum approved by the ADHA, which prepares the dental hygienist to provide diagnostic, preventive, restorative and therapeutic services directly to the public.

• Response to 2000 US Surgeon General’s Report

Where is it?

• Currently a proposed modelpublic health settingsschoolsfederally qualified health centers (FQHCs)long-term care facilitieshospitalsnursing homes

• State by state, currently none in full form

Training & Curriculum

• Training requirements & curriculum not fully established

• Bachelor’s degree + 2 years = Registered Dental Hygienist

• RDH + 2 year Master’s level program

Scope of Practice• Hygiene

• Dx + Perio eval, SRP, Prophy, Fluoride Tx, OHI• Restorative

• Dx + Direct Restorations (composites, amalgams, sealants)• Palliative Care

• Temp restorations, pre-formed crowns, pulp caps, place & remove sutures

• Prosthodontics• Adjust & repair removable, re-cement fixed

• Surgery – dx, uncomplicated extractions• Path – dx & refer• Ortho – dx & refer• Anesthesia – local & N2O*dentist supervision not required

The Dental Therapy ModelBen YouelDistrict 7 Trustee

A Little History

• December 2006 – ADHP program approved by Board of Directors of MN State Colleges & Universities System

• Spring 2007 – Safety Net Coalition (SNC) convinces MN Legislative Committee on Health Care Access to recommend the creation of a dental MLP

• February 2008 – SNC introduces bill to create ADHP in MN Dental Practice Act

A Little More History

• April 2008 – Bill passes to begin creation of an “Oral Health Practitioner”

• April 2008 – U of MN unveiled proposed Dental Therapy program

• May, July & September 2008 – U of MN delegation visits Saskatchewan, New Zealand & England

• Early 2009 – “Dueling Bills” from U of MN/MDA & from the SNC

• December 2011 – Nine students graduated with either Bachelors or Masters Degrees in Dental Therapy from U of MN

• May 2009 – A compromise reached: Dental Therapy (DT) & Advanced Dental Therapy (ADT) created

• Fall 2009 – DT program begins at U of MN & Oral Health Care Practitioner (OHCP) program at Metropolitan State University

• June 2011 – Seven students graduated with MS: OHCP from Metropolitan State

And Finally…

Licensure• Dental Therapist

• Graduate w/Baccalaureate or Master’s in accredited dental therapy education program

• Pass independent clinical competency exam

• Jurisprudence Exam

• Advanced Dental Therapist• All requirements of Dental

Therapist• 2,000 hours of practice as DT• Graduate w/Master’s in ADT• Pass board-approved

competency exam• Apply for certification

Scope of Practice & Supervision• Dental Therapist

• Radiographs• Preventative Procedures & OHI• Sealants• Temporary Restorations• Space Maintainers*• Direct Restorations*• Pre-fab Crowns*• Pulpotomies (Primary teeth)*• Extractions (Erupted primary teeth)*• Tooth Reimplantation/Stabilization*• Local Anesthesia & Nitrous Oxide• Mouthguards• Provide, Dispense & Administer

Analgesics, Anti-Inflammatories & Antibiotics

*Require Indirect SupervisionAll duties subject to Collaborative

Management Agreement (CMA)

• Advanced Dental Therapist**• All duties of Dental Therapist• Oral Evaluations & Assessments• Extraction (Periodontally involved

permanent teeth)**All Require Only General Supervision

A Brief Summary of the MLPs

• DHAT = Alaska (trained in University of Washington)• CDHC = University of Oklahoma, Temple University, &

A.T. Still University Arizona School of Dentistry; New Mexico

• ADHP = Nowhere • Dental Therapist / Advanced Dental Therapist =

Minnesota

Locations

All can do:• Collect information (photographs, radiographs)• Screenings• Fluoride treatments• Sealants• Temporary fillings (IRM)

What can each program do?

What can each program do?CDHC DT DHAT ADHP

TriageDevelop and implement community education programs

Direct RestorationsPre-formed crownsPrimary teeth extractionPerio-involved perm teeth extraction (ADT)Pulp cappingPulpotomiesLocal/NitrousProvide & administer analgesics, anti-inflammatories and antibiotics (ADT)Dx & Tx Planning (ADT)Repair removable prosRe-cement fixed prosSpace maintainersSplinting

Full hygiene scopeDirect RestorationsPre-formed crownsPrimary tooth extractionNon-surgical perm teeth extractionPulpotomiesLocal

Full hygiene scopeDirect RestorationsPre-formed crowns“Uncomplicated extractions”Repair removable prosRe-cement fixed pros

What is the opinion of American Dental Students?

ASDA C-1 Policy:• Only the dentist should perform the following functions. These

functions include but are not limited to:• Examination, diagnosis and treatment planning• Prescribing work authorizations• Performing irreversible dental procedures• Prescribing drugs and/or other medications

ASDA C-2 Policy:ASDA is strongly opposed to independent dental hygiene

practice, and favors the team approach for providing comprehensive dental care.

Resources

• www.asdanet.org - ASDA• www.ada.org - ADA• www.adha.org - ADHA• www.dentistry.umn.edu – U of MN• www.metrostate.edu – Metropolitan State U• www.ykhc.org – Yukon-Kuskokwim Health Corporation• www.wkkf.org – W.K. Kellogg Foundation

Questions?

uicasda@gmail.com