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Start-up company

Jan. 1, 2012
When she walked into the Skilled Nursing Facility (SNF), a young woman greeted her. “Melissa, I did not brush yet this morning, but I did twice yesterday!”

As a California RDHAP, Melissa Hall reaches out to the underserved in skilled nursing facilities.

for managing the Independent Practice Dental Hygienist

by Noel Kelsch, RDHAP

When she walked into the Skilled Nursing Facility (SNF), a young woman greeted her.

“Melissa, I did not brush yet this morning, but I did twice yesterday!”

The staff and clients know her by name and appreciate all the efforts that she has made to deliver care to those who have not had an opportunity in the past.

When Melissa Hall completed school to become a registered dental hygienist in alternative practice (RDHAP), she did not feel armed with the details of running a dental hygiene business. She felt that what she was doing was based on trial and error. She wanted something that would tell her step by step the process of developing a business of her own. She felt the learning curve was just too much for the RDHAP.

Six months ago, Melissa started a company that could do all of the business of RDHAPs and allow them to go directly to the patient and complete their work, leaving the billing and securing of clients to someone else. She also wanted to create and develop teams that not only will be able to deliver great clinical care, but can mesh themselves into the fabric of the facilities. The facilities and the patients are in such dire need of quality care and education. The corporation that Melissa spearheaded is called Healthy Smiles of California (HSC).

Mission statement

HSC uses a quote as a mission statement: “Sometimes you have to jump off cliffs and grow wings on the way down.” ~Ray Bradbury, 1920.

Business model

The business model that HCS uses is the dental office team approach. Melissa plans on utilizing a group National Provider Number (NPI) so that billing can be done as a group practice. There is an administrative CEO who works out of Melissa’s home office. The CEO handles billing, marketing, scheduling, and administrative duties. HSC also has a corporate building that allows them to use office space for meetings as needed. As they grow, they are expanding time at the corporate facility.

“The purpose of HCS is to allow the hygienists who are RDHAPs to work in this setting and not have to do the business end of the profession and have the backup of working with a team. My personal take on the team approach stems from my personal comfort level. I feel more safe and secure with a team. I guess it comes from always working as a team in the dental office. I also recognized that when I had meetings with nursing facilities, the question always came up, ‘What would happen if you got hit by a bus?’ I think that since these facilities work off the same premise, this concept seems safe and makes sense to them as well,” Melissa shared.

Where it began

Melissa spent much of her time after graduation reaching out to other RDHAP professionals to understand the workings of the profession. She gleaned as much information as she could from RDHAPs who had experience and successful practices. Tidbits that she got from other RDHAPs were the starting point for gathering equipment, determining fees, ordering supplies, etc.

Melissa hit the pavement running! She went from skilled nursing facility (SNF) to intermediate care facilities (ICF) making people aware of her services. She spent many hours making staff and families aware of the importance of oralcare and the role of the RDHAP. Finally, after 12 months, she was offered a contract for services.

Current business

Including Melissa there are three registered dental hygienists in alternative practice working for HSC. This start-up company sees an average of 45 patients a week. They are expanding their work base by obtaining more contracts.

Melissa currently works three days a week in general practice and two days a week in this RDHAP setting.

“This was a major investment and it takes lot of time and energy to bring it forward. This is not a business for the faint at heart.”

The benefits of working under this business model are:

  • Percentage of production goes to the RDHAP and a percentage to the company
  • The company does billing and insurance
  • The company does scheduling
  • Contracts are developed and obtained by the company
  • Ancillary personnel are hired by company and paid by company
  • The company supplies oral care supplies

Duties and style

HSC has its hygienists working bedside. They do all the duties that they would perform in the dental office under general supervision without the supervision of a dentist. They utilize a basic setup and hand instruments. They have the patient expectorate into a cup. RDHAPs must bring their own instruments and disposable supplies to the facility as well as sterilize their own instruments.

Melissa’s vision continues to grow and expand. Her efforts to streamline the process and handle the business of RDHAP practices are moving forward. Her clients reflect her efforts in their smiles.

Noel Brandon Kelsch, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.

What is an RDHAP?

In California an RDHAP is a registered dental hygienist in alternative practice. RDHAPs have specialized training and an additional license that allows them to have their own independent business and work in settings other than a dental office and without the supervision of a dentist. These services can be provided in designated underserved areas, as well as schools, institutions, residences, skilled nursing facilities, and private homes of homebound persons. This model reaches some of the most underserved populations.

Services include: oral evaluations, oral care plans, customized direct care staff in-service training for providing resident oral care, in-residence and bedside dental hygiene care, and prevention.

Laws, Rights, and Access to Dental Hygiene Care

Since 1995, the number of direct access states has risen from five states to 32.

Within those states the laws vary. Federal laws protect the rights of the client as well as the rights of hygienists to utilize free enterprise.

Federal laws allow free enterprise in all areas of health care. Any dental hygienist can approach an SNF or ICF and offer their services as long as their state practice act allows them to. It is important to note that many states currently do not allow this form of practice. For a complete listing of each state’s laws and regulations, go to:c

This chart also reviews the level of supervision, reimbursement from Medicaid reimbursement, and current allowable duties.

Federal law gives patients the right to choose a health-care provider. It is important that when you establish a relationship with a client, you have them or their guardian designate you as their provider in writing. If the facility rescinds a contract, you are able to still meet your clients’ needs and not abandon them because of contract issues.

Some tips from Melissa

1. HCS has found that having technology available is one of the most important tools. They utilize a dental Internet software company including billing, so HSC can be mobile and interconnected with the entire HSC team. Staff members use walkie-talkies to save time and steps. They do not have to run around looking for the dental assistant or patients. All team members carry a computer, a portable printer, and a walkie-talkie.
2. Like most RDHAPs, the team uses a cargo box, a huge black container box where you can store extra cables, cords, electric strips, clocks, dental supplies, goodie bags for patients, and little treasures to thank the staff for being so helpful.
3. Communicate with the doctors at the facilities by first sending them an introduction email and then calling them. Always ask how they would like to communicate. Send observations to the dentist who is contracted by the facility on a dental referral form. This aids in the cohesiveness between the RDHAP and the dentist.

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