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The Washington Advantage

May 1, 2004
It's a business opportunity, but, more importantly, it's an alternative for delivering care to underserved areas.

by Shirley Gutkowski, RDH, BSDH

Most hygienists work in a clinical practice, seeing patients one at a time at a central location. Patients arrive under their own power, and, even if they don't want to be there, they are cooperative. In most cases, the hygienists work with a dentist and his or her staff. It's rare to find hygienists who work for corporations, in public health, or some of the other settings of dental hygiene practice. Our jobs are interesting — something new every day or every hour. Even though each patient is different, over the years the job can become tedious. Every so often, a new item will be added to the dental hygiene scope of practice (for example, anesthetic delivery), which helps keep things new and interesting. For some hygienists though, it can be the same old faces, same old conditions, and same old lectures.

In some states, the options for dental hygiene practice are a little different — wider, roomier, and more versatile. In other states, someone outside of the dental field takes the practice acts and wrenches them into something that no dental health-care provider would ever have thought of.

In Florida, one entrepreneur found a little leeway in the rules and capitalized on this tiny crack in the statutes. He hired dentists to do exams and hygienists to provide preventive services by prescription for residents in long-term care facilities. The company has a staff of people calling the financial directors for each resident to set up appointments for the care. He's filling a gap in the system left by organized dentistry. In Florida, an outsider set the hygienists free.

In Washington state, hygienists set themselves free. In the early 1980s, hygienists organized, hired a lobbyist, and petitioned legislators to allow hygienists to practice without supervision of a dentist, in order to reach some of the most fragile and vulnerable of the "shut away" populations in the state ... and they won. Since 1984, hygienists in Washington have been allowed to practice unsupervised in hospitals, nursing homes, long-term care facilities, group homes for the disabled, and penal and juvenile detention facilities. Some hygienists with an entrepreneurial spirit started businesses of their own right away, traveling around their counties or beyond, seeing patients that had no ability to be seen in traditional dental offices. In 1997, legislators added community, tribal and migrant clinics to the list of settings where dental hygienists may practice without a dentist's supervision.

These practices are different from the New Mexico model. Although the statute has been on the books for a couple of years, the rules haven't been finalized. New Mexico hygienists can work in direct collaboration with one or more dentists. They can see patients and refer them for treatment directly to the dentists that they're contracted with.

Anita Munson Brock, RDH, participates in a Special Olympics event
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In Washington, there are no formal collaborations mandated. Hygienists often work with one or more dentists in their geographical area, if they can find one who isn't feeling threatened. Many are, or more likely just do not understand the law that permits hygienists to practice in the community.

Anita receives a hug above from a grateful patient.
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There is a mighty group of hygienists in Washington, some 50 in all, who take care of those who cannot or will not access private practices. These hygienists see the patients that would normally fall through the cracks. They can freely contract with schools or residential health care facilities, and then set up screening and preventive care days in those schools or facilities. They hire employees, own fully equipped dental vans to see patients near the patients' home, and make a happy living doing it.

A typical day might look like this:
• 7 a.m. — Get up to go to work. The mobile clinic is already parked at the school. Children who have returned consent forms were pre-screened the day before.
• 8 a.m. — Join the dental assistants who have already begun organizing and laying out supplies and paperwork for the day.
• 9 a.m. — Provide oral hygiene instruction, sealants and fluoride varnishes for 25 eligible children.
• 3:30 p.m. — Clean up, sterilize instruments, and finish the paperwork and referral slips for the children seen that day.
• 4:30 p.m. — Drive home.

Every week or so, the mobile clinic must be packed and moved to the next school that has already been visited, consent forms given and collected, insurances verified, and charts made by the office manager.

Or a day may look like this:
• 6 a.m. — Get up to go to work.
• 7 a.m. — Drive to the group home. The van is packed with the equipment, supplies and patient charts for the day.
• 8 a.m. — Set up and provide preventive services for the five residents that live there.
• Noon — Break down and drive to the long-term care facility.
• 1 p.m. — Set up and provide evaluations and preventive care for three of the residents.
• 4 p.m. — Pack up and drive back home.
• 7 p.m. — After dinner, bill Medical Assistance or patients' families for reimbursement. Get reports to dentists of record ready for the mail.

This is exactly how Washington State dental hygienists Kerry Warden, RDH, and Anita Munson Brock, RDH, make their living.

Kerry runs school-based programs focusing mainly on providing sealants, fluoride varnishes, and preventive education for school children. She sees some adults in the summer when school is out, but her focus is children. She has five employees. One other hygienist and three dental assistants work with her in the 36-foot mobile clinic most of the time. An office manager works in the home office and handles all the billing, reconciling, and coordination of the school visits.

The mobile clinic has two operatories and, in true multitasking form, Kerry sees a patient in one chair with one assistant, while another assistant tears down and sets up the other operatory. Her patients are children in elementary schools who have returned consent forms signed by parents in order to receive a dental screening and preventive services.

Anita mainly sees adults with developmental disabilities like Down's syndrome, cerebral palsy, and acquired disabilities such dementia and Alzheimer's disease. She packs her mobile equipment into a standard minivan and sets up in each of the homes she visits. Her schedule of four- to six-month visits includes patients in five Washington counties. She started two local preventive programs for adults with disabilities — one for a large mental health population in desperate need of dental services, and one for adults with developmental disabilities at the community clinic where she got her start in community health. She is contracted with a local Job Corps facility to provide clinical services and dental hygiene assistant training for at-risk teens. Anita also subcontracts to three other hygienists to provide care at two long-term care facilities for seniors, a children's project on the east side of the state, and to do oral health care training for caregivers. Tired yet? A suspected workaholic, Anita is also finishing her baccalaureate degree and plans to graduate some time in 2004.

The mobile clinic above was the first one for Kerry Warden, RDH. The customized paint job included the slogan depicted in the center photograph. After a year, Warden moved her operations into the mobile clinic below.
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Both Kerry and Anita find the work extremely rewarding and gratifying. Their talents and education are fully utilized. They get hugs, blessings, and thank-yous from some of the most needy in their communities. They're not held back by an employer's production schedule or protocol ... well, mostly not held back. Although not as barefaced as the Dental Examining Board's vicious attack in North Carolina — changing state rules to drive one hygienist's outreach practice out of business — the free-spirited hygienists in Washington State still have to battle the narrow minds and misconceptions of some. Hygienists have endured harassment exhibited as slanderous mail and threatening phone calls to the facilities they work with. Blatant lies about clinical skills and dental hygiene education are not out of the question for the ethically vacuous. The jealous rancor is delivered to patients in the very practices that enjoy the income of the cases referred by these hygienists.

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Practicing fully within the confines of the law, doing everything to prevent disease and improve the lives of their patients, this slander is personally agonizing for the hygienists involved, and detrimental to the health of the patients and even the doctor's business. Some harassment has been vicious enough for the hygienists to half-jokingly tell family members to look at Dr. So-and-so if their dead body is ever found in the river.

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Competition for dollars is fierce in the school sealant programs because low-income children have the greatest priority from state funding. During legislative negotiations for a school sealant bill in 2001, the dental association demanded that assistants also be allowed to place sealants on school children after a dentist's screening, under the dentist's general supervision. That means that dentists can screen kids one day, then send their assistants, who may have as little as five weeks' training, to place the sealants. The dentist is not required to ensure the quality of care, or to evaluate the sealants for retention. It's kind of a "seal and run" operation.

The most grating issue is that only a handful of providers, mainly dental hygienists, paid much attention to the preventive needs of the children in the state before the bill passed. Now professionals are squabbling over federal and state money that sealing teeth can provide. Some are out to make a buck with the sealant programs without ethical commitments. Fortunately, some school administrators and school nurses have noticed the differences in care, outcomes, and follow-through between hygienist-run programs and dentist/dental assistant programs. It seems that, regardless of any law, there are always going to be people who take advantage of any situation. Hygienist programs continue to survive because of their high quality and follow-through. Their disease control and sealant-retention rates prove it. And their customers, the schools, remain loyal to hygienists willing to make long-term commitments to their children.

Competition isn't as fierce for the hygienists who treat the elderly and other mentally or physically challenged populations. It's a tough crowd and a special kind of provider is needed to address their conditions. Anita got her basic training from the University of Washington Dental Education in the Care Of the Disabled (DECOD) program, which teaches all kinds of dental professionals how to work with persons with disabilities. Now, she is on her own, going from site to site providing services and educating her patients as well as their caregivers on proper oral care. She doesn't have as many side issues to deal with as Kerry does. She really has only one: Every two years the state grapples with adult Medicaid funding, and adult dental services are always the first to go on the chopping block, effectively cutting her income. As part of her busy schedule, she follows politics and what's happening at the state capital. "It takes a lot of time and energy to be politically active," according to Anita. "Politics is part of professionalism, especially in health care."

Anita gets to use her talents as a problem solver to help people with developmental and acquired mental and physical disabilities find ways to achieve the best oral health they possibly can. Like small children, some of her patients cannot even tell her that they have pain. She must be diligent in all of her assessments. Sometimes, all she can do is stop the progression of decay, because some of her patients might never be able to find a dentist who will see or treat them. For most dental professionals, a situation like this would be most frustrating. For Anita, halting the progression of disease is a gratifying experience.

The usual outcome from the lack of professional dental attention is pain and suffering. Having little or no preventive care, therapies, or education, the disadvantaged becomes the much feared, often belittled, barely tolerated walk-in patient. The expanding model of dental care delivery in Washington, like that in New Mexico and other states, is ideal for patients, hygienists, and most of the dentists. People in the dark corners of the state can receive preventive care and dentists can stop feeling guilty for not going out into the world to treat them. Hygienists can own and operate their own dental hygiene practices. It's an access success story.

So why isn't every hygienist jumping on this most exciting, gratifying way of practicing dental hygiene in Washington? The answer lies in the basic human emotion called fear. For those who may be brave enough to start their own business, fear of retribution and the problems that have plagued Kerry and others keep more from venturing forward. Others just enjoy clocking out at the end of the day, working in a place where they think their needs are taken care of. Over time, though, as the kinks with these new delivery systems are resolved, more hygienists will be realizing the benefits of working for themselves and joining the ranks of the pioneers.

The 50 Washington hygienists that do practice this way recently formed an organization called the Alliance of Dental Hygiene Practitioners. Their mission is to provide cost-effective, preventive oral health care services and education. They support consumer choice, community partnerships, and access to care throughout the state of Washington. Partly supported by the Washington State Dental Hygienists' annual sessions, members of the Alliance meet at least twice a year to network among themselves. Kerry and Anita's advice to hygienists around the country is to look into their own state practice acts and find ways, within those confines, to develop creative solutions to reach the populations they care most about. Like the glass half full, there is opportunity in every practice act, if you look. That's how change happened in Washington, and they're confident it will work that way for others.

Shirley Gutkowski, RDH, BSDH, has been a practicing dental hygienist since 1986. She is a popular speaker and award-winning author. Gutkowski and Amy Nieves, RDH, are the co-authors of "The Purple Guide: Developing Your Dental Hygiene Career," a handbook for graduates from dental hygiene school. Gutkowski can be contacted at [email protected].