by JoAnn R. Gurenlian, RDH, PhD
Last month, the Institute of Oral Medicine (IOM) released a report titled "Improving Access to Oral Health Care for Vulnerable and Underserved Populations." This report details concerns about the lack of oral health care in our nation among children, elderly, racial and ethnic minorities, people with special needs, pregnant women, those living in rural areas, and those of lower socioeconomic status.
The IOM established a committee of experts to "assess the current oral health care system, to develop a vision to improve oral health care for vulnerable and underserved populations, and to recommend strategies to achieve the vision."1
This vision established for oral health is one in which every person in the United States has access to quality oral health care across the life span. To accomplish this vision, the committee proposed an evidence-based oral health care approach that will accomplish the following:
- Eliminate barriers that contribute to oral health disparities.
- Prioritize disease prevention and health promotion.
- Provide oral health services in a variety of settings.
- Rely on a diverse and expanded array of providers who are competent, compensated, and authorized to provide evidence-based care.
- Include collaborative and multidisciplinary teams working across the health care system.
- Foster continuous improvement and innovation.2
After reviewing the evidence, the committee established 10 recommendations to improve access to oral health care for underserved and vulnerable populations. These recommendations are summarized at the end of this article. To view the full report, visit http://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx.
Of particular interest in the report was the discussion concerning creating optimal laws and regulations. The committee acknowledged the need to eliminate barriers to oral health care access. The committee noted that there are overly restrictive regulations and considerable variability among states in terms of supervision levels and scope of practice. The committee proposed that state laws be amended to maximize access to oral health care and allow professionals to practice to the full extent of their education and training in a variety of settings.
When this report was released by the IOM, the ADHA released a statement saluting the IOM committee for its vision and initiatives designed to help eliminate barriers and end the access to oral health care crisis. However, not all health care organizations are as supportive of the proposed recommendations. The day the report was released, the Academy of General Dentistry (AGD) issued a statement expressing concern that the IOM committee did not include private practice dentists as members. Further, the AGD did not support the recommendation "that remote supervision of an allied dental professional will provide the public with access to high-quality care."3 The AGD holds the position that implementing this strategy "could put our most vulnerable citizens at an even greater disadvantage and result in an increased threat to establishing and maintaining proper oral health."3
It may well be that the AGD is the only dental professional organization that shares these concerns; in time others may come forward with similar issues. What remains to be seen, however, is whether or not dentists and dental hygienists will rise to the challenge of improving access to oral health care.
It seems like every few years there is a government-generated report that makes similar recommendations for improving the oral health of the public, but we just cannot get past the state regulatory barriers. It would be terribly sad if, once again, we missed the opportunity to improve oral health care for all by becoming mired in unsubstantiated issues and territoriality at the expense of the health of the public. One of the ways dental hygienists can prevent this from happening is by taking action to ensure that we are addressing and implementing the recommendations proposed by the IOM committee and documenting the outcomes. Armed with additional evidence of the impact of dental hygienists fully applying their education in underserved and vulnerable populations may be the approach that helps to assure organizations such as the AGD that safe, effective, quality oral health care can be delivered without jeopardizing the oral health of the public.
Recommendations for improving access to oral health care for vulnerable and underserved populations
Category: Integrating Oral Health Care into Overall Health Care
♦ 1a. The Healthcare Resources and Services Administration (HRSA) should convene stakeholders from both the public and private sectors to develop a core set of oral health competencies for health care professionals.
♦ 1b. Following the development of a core set of oral health competencies for nondental health care professionals:
- Accrediting bodies for undergraduate and graduate-level nondental health care professional education programs should integrate these core competencies into their requirements for accreditation.
- All certification and maintenance of certification for health care professionals should include demonstration of competence in oral health care as a criterion.
Category: Creating Optimal Laws and Regulations
♦ 2. State legislatures should amend existing state laws, including practice acts, to optimize access to oral health care.
At a minimum, state dental practice acts should:
- Allow allied dental professionals to practice to the full extent of their education and training.
- Allow allied dental professionals to work in a variety of settings under evidence-supported supervision levels.
- Allow technology-supported remote collaboration and supervision.
Category: Improving Dental Education and Training
♦ 3. Dental professional education programs should:
- Increase recruitment and support for enrollment of students from underrepresented minority, lower income, and rural populations.
- Require all students to participate in community-based education rotations with opportunities to work with interdisciplinary teams.
- Recruit and retain faculty with experience and expertise in caring for underserved and vulnerable populations.
♦ 4. HRSA should dedicate Title VII funding to:
- Support the development, implementation, and maintenance of substantial community-based education rotations.
- Increase funding for recruitment and scholarships for underrepresented minorities, lower income, and rural populations to attend dental professional schools.
♦ 5. HRSA should dedicate Title VII funding to support and expand opportunities for dental residencies in community-based settings.
Subsequently, state legislatures should require a minimum of one year of dental residency before a dentist can be licensed to practice.
Category: Reducing Financial and Administrative Barriers
♦ 6. The Centers for Medicare and Medicaid Services (CMS) should fund and evaluate state-based demonstration projects that cover essential oral health benefits for Medicaid beneficiaries.
♦ 7. To increase provider participation in publicly funded programs, states should:
- Set Medicaid and CHIP reimbursement rates so that beneficiaries have equitable access to essential oral health services, as required by laws.
- Provide case-management services.
- Streamline administrative processes.
Category: Promoting Research
♦ 8. Congress, the Department of Health and Human Services (HHS), federal agencies, and private foundations should increase funding for oral health research and evaluation related to underserved and vulnerable populations, including:
- New methods and technologies (e.g., nontraditional settings, nondental professionals, new provider types, and telehealth).
- Measures of access, quality, and outcomes.
- Payment and regulatory systems.
Category: Expanding Capacity
♦ 9. The Centers for Disease Control and Prevention (CDC) and the Maternal and Child Health Bureau (MCHB) should collaborate with states to ensure that each state has the infrastructure and support necessary to perform core dental public health functions (e.g., assessment, policy development, and assurance).
♦ 10. To expand the capacity of federally qualified health centers (FQHCs) to deliver essential oral health services, HRSA should:
- Support the use of a variety of oral health care professionals.
- Enhance financial incentives to attract and retain more oral health care professionals.
- Provide guidance to implement best practices in management, operation, and efficiency.
- Assist FQHCs (Author: please define FQHC) in all states to operate programs outside their physical facilities and take advantage of new systems to improve the oral health of the population they serve.
Source: (IOM) Institute of Medicine and (NRC) National Research Council. 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.
1. (IOM) Institute of Medicine and (NRC) National Research Council. 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.
2. Report Brief. July 2011. Improving access to oral health care for vulnerable and underserved populations. Available at: http://www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx. Accessed July 18, 2011.
3. Academy of General Dentistry. AGD responds to inaccuracies in the Institute of Medicine’s Report. Press release July 13, 2011.
JoAnn R. Gurenlian, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing-education programs to health-care providers. She is a professor and interim dental hygiene graduate program director at Idaho State University, adjunct faculty at Burlington County College and Montgomery County College, and president-elect of the International Federation of Dental Hygienists.
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