Improving oral health through community-based interventions
Analysis of the factors that allow people to live long, healthy lives reveals that the most important factor is behaviors that can be controlled by the individual (McGinnis & Foege 1993; McGinnis et al. 2002). In fact, the factors that lead to long, healthy lives can be grouped roughly as follows:
- 40%—individual behaviors. Examples include reduction or elimination of the use of tobacco, moderate consumption of alcohol, and in the case of oral health, plaque removal and use of fluoride and other products that alter the oral environment.
- 30%—genetics. At present we can only mitigate a small number of the genetic factors that cause disability, illness, and early death, although there are many treatments available for the results of our genetic makeup and new discoveries being made in this area at a dramatic rate.
- 20%—environment and public health measures. These include steps to reduce pollution, overcrowding, and stress, and public health measures such as sanitation, immunization, and fluoridation of the drinking water.
- 10%—procedures performed by health care professionals.
The last bullet point should get our attention. We put most of our health care resources in the United States into procedures performed by heath care professionals, and yet they account for such a small portion of the factors that lead to long, healthy lives.
Although the data described above come from an analysis of general health conditions, it seems likely that roughly the same proportions would hold for oral health. If this is the case, then it follows that to keep a population of people having good oral health requires more emphasis on influencing behaviors and less on relying on oral health professionals to repair the ravages of disease after they have occurred. This is especially true when considering people with disabilities, where, in general, treatment of existing disease is more complex and at times more costly than with other segments of the population (Glassman & Miller 2009).
Another issue to consider is the reach of office-based oral health care. Over 30% of the population does not take advantage of the traditional office-based dental delivery system (ADA 2006). This proportion is even higher in people with low income and those with physical and medical disabilities. Since disability is often associated with low income, and people with disabilities may be more difficult to treat, they are among the least likely to receive oral health care in traditional office-based delivery systems and have been identified as being among the populations with the greatest oral health disparities (U.S. Bureau of the Census 1997; Stiefel 2001; U.S. Department of Health and Human Services 2000).
In addition, consider the ability of office-based practices to influence individual behaviors and emphasize prevention and early intervention. This is challenging for several reasons. First, as indicated above, people with disabilities are among the least likely to take advantage of office-based care. In addition, dental offices are intimidating for many people and are not the environment where people are the most open and ready to listen to and integrate oral health messages. Also, the economics of dental practice encourages providers to spend the majority of their time and effort on technical procedures requiring the sophisticated equipment and the highly skilled professionals found in these environments.
All of these factors lead to the conclusion that systems capable of influencing individual behaviors and emphasizing prevention and early intervention may best be developed and delivered in community settings. This chapter will describe what the author means by community-based settings and provide examples of community-based systems that have been shown to be effective in improving the oral health of people with disabilities.
WHAT ARE COMMUNITY-BASED SETTINGS AND COMMUNITY-BASED SYSTEMS OF CARE?
As used in this chapter, the term “community-based settings” can include any location outside of a dental office environment. However, the emphasis in this chapter will be on settings where people may be grouped together to receive social, general health, or educational services. Many people with disabilities, particularly those with significant disabilities, live or spend time in group settings (Glassman & Subar 2010). Group settings can include schools, group residential facilities, long-term care facilities, and child and adult day-care settings. People with disabilities may also be seen by numerous social and health professionals in the process of receiving home-based social and general health services. All of these sites and situations present opportunities to integrate oral health activities with the activities of professionals, staff, and caregivers who interact with people with disabilities in community settings.
Community-based systems of care are delivery mechanisms that take place within the context of the services and settings just described. There are a number of common elements that may be included in oral health care that is delivered in community-based oral health systems. These include case management, community-based health education, community-based prevention procedures, community-based therapeutic interventions, and elements of the patient-centered health home (ADA 2004; Bernabei et al. 1998; DeBate et al. 2006; Park et al. 2009; Mertz & O’Neil 2002; Zittel-Palamara et al. 2005).
The patient-centered health home has been described as a system of care that provides care management over time; health promotion activities; access to technical medical services when needed; and in pediatric medical home models, there is also an emphasis on early intervention services (Beal et al. 2007). Many descriptions of medical homes or health homes describe them as taking place within the primary physician’s or dentist’s office (American Academy of Pediatric Dentistry 2011; National Association of State Health Policy 2009). However, there is increasing realization that the elements of a patient-centered health home can be achieved by many different structures and the primary care provider’s office does not need to be the center of the entity that delivers and coordinates these services (Pacific Center for Special Care 2011).
The remainder of this chapter will describe several examples of community-based systems that can create or extend components of the patient-centered health home to people with disabilities.
EXAMPLES OF COMMUNITY-BASED SYSTEMS OF CARE
The dental coordinator model
There are numerous examples of systems that deliver oral health services and improve the oral health of people with disabilities in community settings. Almost 2 decades ago the Pacific Center for Special Care created a community-based system of care in conjunction with the California Regional Center System (Glassman & Miller 1994, 1998, 2009; Glassman et al. 1996). Regional Centers are social service agencies with long-term contracts with the California Department of Developmental Services that provide assessment, case management, and referral services for people with developmental disabilities. The center of the oral health system is an individual referred to as the “Dental Coordinator” (DC). Dental Coordinators are primarily dental hygienists who work for and sometimes in the Regional Center office in communities across California. They act as a “dental case manager.” Their role includes the following activities:
- Leverage local resources—this involves determining what resources already exist in a community and facilitating communication among those resources. In many communities, there a/>