Social work programs in dental schools and dental clinics have been operated successfully since the 1940s, and have been documented as contributing to patients’ access to care and to dental education. However, unlike medical social work, with which it has much in common, social work in dentistry has failed to become a standard feature of dental schools and clinics. Few of the social work initiatives that have been implemented in dental schools have survived after initial grant funding ran out, or the institutional supporters of the program moved on. The authors hope that the CARES program serves as a model for the successful development of other programs at the intersection of social work and dentistry to the benefit of both dental patients and providers.
In recent years, disparities in oral health care and difficulties in accessing oral health care have been the object of increasing public concern. Many Americans lack dental insurance, an increasing number of dentists in private practice refuse to accept Medicaid, and the escalating costs of dental care put even routine care outside the reach of a growing number of people. Although the cost of dental care provided by dental schools is typically far less than that of the same services provided by private dentists, financial concerns and difficulties with transportation, dental anxiety, mental health issues, physical health problems, and disabilities still make it difficult for many patients to complete needed dental treatment. CARES, the Counseling, Advocacy, Referral Education and Service program at the University of Buffalo School of Dental Medicine (SDM), was created to help patients overcome these difficulties, so they can receive much needed treatment. While there is no such thing as a ”typical” dental patient, the following patients who were referred to the CARES program are representative of many patients treated at the University at Buffalo SDM and at other dental schools around the country.
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Mrs. K is a veteran who is in need of extractions and dentures, and does not have the ability to pay for dental treatment. She was not eligible for treatment at the VA hospital, because her dental problems are not related to injuries sustained during her military service.
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Mrs. R is in her 50s and is disabled by a number of health conditions, including lupus, fibromyalgia, high blood pressure, hyperthyroidism, gastrointestinal problems, anxiety, and major depressive disorder. Her husband, also in his 50s, is retired. They have one adult child, who has pervasive developmental disabilities. Because of their limited income and the high cost of their other medical bills, Mrs. R has been unable to afford dental care.
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Mrs. T is 85 years of age, widowed, and suffering from angina, dementia, diabetes, arthritis, hypertension, and the sequelae of a stroke. She subsists on Social Security, which pays her $760 per month, an amount that barely covers living expenses, let alone the dental treatment she needs.
According to a 1998 survey conducted by the American Dental Association (ADA), individuals with low incomes were the most frequently reported special population receiving care at dental school clinics in the United States, followed by individuals with mental, medical, or physical disabilities. In fact, the majority of patients treated at dental school clinics came from households whose annual income was estimated to be $15,000 or less. As might be expected, many of these patients were uninsured or underinsured, 50% were covered by Medicaid or Medicare, and an additional 32% had no private dental insurance.
As Haden and colleagues observe, “as providers of care, academic dental institutions are a safety net for the underserved, centers of pioneering tertiary care, and contributors to the well being of their patients through accessible oral health care services.” Unfortunately, the various components of this mission may be compromised when patients struggling with the difficulties presented by poverty or disability fail to comply with treatment plans or miss appointments, causing students to lose precious clinic hours. In the University at Buffalo SDM, a creative and successful solution was found to address the problem of achieving both the education and service aspects of its mission, with the creation of the CARES program.
The above considerations indicate that, in providing treatment in a dental school clinic, students, faculty, and staff are forced to deal with problems that are not limited to oral health, but rather, are psychosocial in nature. In short, dentists treat not teeth, but people. Because social workers are trained not only to deal with intrapsychic problems but also problems within social systems, they are uniquely qualified to assist patients dealing with complex psychosocial issues and to help both patients and providers navigate the complex health care and social service systems. It is this observation that inspired the development of the CARES program at the University at Buffalo SDM, which employs a social work approach to deal with issues of access to care and patient retention.
Origins of the CARES program
In 1999, the Dean of the University at Buffalo SDM, Louis Goldberg, DDS, PhD, and the Dean of the School of Social Work at UB, Laurence Schulman, DSW, had a conversation about the difficulty of patient retention and the barriers to care experienced by patients in the University at Buffalo SDM clinics. As Goldberg recalled, “We have social work problems, you have a school of Social Work, let’s do something together.” This conversation became the genesis of the CARES program, an innovative collaborative effort between the two schools to address issues of access to dental care. The objective of the program was to address financial, psychological, and social needs, which create barriers to dental care. Although other, similar programs have been created in dental schools in the past, the CARES program, with a current staff of three full-time social workers and one part-time, grant-funded social worker, is one of the largest, and to our knowledge, longest running programs of it kind.
Initial funding was provided by a grant from the Community Foundation for Greater Buffalo in 2000. Some of this funding was used to conduct a needs assessment designed in part to answer the question, “Are there significant health and social concerns within the dental clinic population that indicate the need for high-risk screening and social work services?” Nine hundred twenty-eight dental patients were surveyed, and results indicated that health (32%), finances (25%), medical bills, (16%) and family issues (14%) were the primary concerns identified by clinic patients. Approximately 42% of the respondents were living below the poverty level. In-depth interviews were then conducted with 157 survey respondents, and the information they provided as well as the data from the survey were used to develop the CARES program.
In the fall of 2001, the program opened its doors. Funds from the community foundation grant were used to hire a part-time master’s-level social worker (MSW) to work with patients seen in the dental clinic and to supervise two MSW student interns who were assigned to the CARES program for their field placement. In its first year, 27 patients were referred to the CARES program.
Growth of the program
During the second year of operation, the program expanded its initial focus on underserved older adults to include children, low-income patients, patients without insurance, and patients with complex health or mental health problems. In addition, the social worker began working with the dentists and the physical therapist in the Orofacial Pain Clinic and Temporomandibular Disorders Clinic at the University at Buffalo SDM to provide psychosocial treatment for patients experiencing temporomandibular joint disorders (TMD). Social work interventions in the clinic include progressive muscle relaxation, guided imagery, deep-breathing exercises, social skills training for anxiety and depression, and pain management skills. Finally, outreach was conducted in local senior centers to educate seniors about oral health, services offered in the University at Buffalo SDM, and how CARES staff could assist them in obtaining dental care.
During this second year, the University at Buffalo SDM, assumed financial responsibility for the CARES program, which it has supported ever since. In its third year, the school increased program support to provide a full-time social worker, and by its fifth year of operations, the CARES program employed two full time master’s level social workers. In 2007, a doctoral level social worker was hired as Research Director for the program; this faculty appointment is funded jointly by the Department of Pediatric and Community Dentistry in the SDM and the School of Social Work. In 2008, funding was obtained through the Dental Trade Alliance Foundation to hire a part-time social worker for the pediatric clinic at the SDM. Each year the program has also served as the field placement site for four to seven MSW students. These students, under the supervision of CARES social work staff, work with their own caseload of CARES patients, enabling more clients to receive social work services. This growth in CARES staff has been spurred by a continuous increase in the number of clients referred. Each year CARES has reached more clients in need of services from 200 in 2002, the second year of operations, to approximately 800 in 2007 ( Fig. 1 ) (CARES annual report, unpublished data, 2007).
The mission of the CARES program is to improve oral health by decreasing barriers to care and improving access to dental treatment for special needs and difficult-to-reach patients. As such, CARES not only addresses the needs of patients in the dental clinic, but also fills a need of the school and its students. By helping patients to access treatment at the dental school, CARES social workers provide important clinic hours for students and help the clinic to generate income for the school. CARES staff also educate students about psychosocial issues that affect a patient’s ability to access care and teach dental students important skills in dentist–patient communication.
As stated above, the mission of a dental school is threefold: to educate dental professionals, to expand the knowledge base of the profession through basic and applied research, and to provide service to the community. This mission is paralleled by the roles of a social worker within a dental school as described by Levy: (1) education and training of dental professionals to improve their interactions with patients, (2) provision of social work clinical services to dental patients, and (3) research that can add to the body of knowledge on patient behaviors relevant to dental treatment.
From the beginning, the leadership in the SDM recognized that the CARES program served not only the needs of the patients, but also the institution. As a result, support for the program from the leadership in the SDM has remained strong despite the vicissitudes of state funding. This support at the top echelons of leadership in the SDM has been a significant factor in the success and longevity of the program. Without the financial commitment of the Dean’s office, it is doubtful that the program would have been able to continue to grow as it has.
Growth of the program
During the second year of operation, the program expanded its initial focus on underserved older adults to include children, low-income patients, patients without insurance, and patients with complex health or mental health problems. In addition, the social worker began working with the dentists and the physical therapist in the Orofacial Pain Clinic and Temporomandibular Disorders Clinic at the University at Buffalo SDM to provide psychosocial treatment for patients experiencing temporomandibular joint disorders (TMD). Social work interventions in the clinic include progressive muscle relaxation, guided imagery, deep-breathing exercises, social skills training for anxiety and depression, and pain management skills. Finally, outreach was conducted in local senior centers to educate seniors about oral health, services offered in the University at Buffalo SDM, and how CARES staff could assist them in obtaining dental care.
During this second year, the University at Buffalo SDM, assumed financial responsibility for the CARES program, which it has supported ever since. In its third year, the school increased program support to provide a full-time social worker, and by its fifth year of operations, the CARES program employed two full time master’s level social workers. In 2007, a doctoral level social worker was hired as Research Director for the program; this faculty appointment is funded jointly by the Department of Pediatric and Community Dentistry in the SDM and the School of Social Work. In 2008, funding was obtained through the Dental Trade Alliance Foundation to hire a part-time social worker for the pediatric clinic at the SDM. Each year the program has also served as the field placement site for four to seven MSW students. These students, under the supervision of CARES social work staff, work with their own caseload of CARES patients, enabling more clients to receive social work services. This growth in CARES staff has been spurred by a continuous increase in the number of clients referred. Each year CARES has reached more clients in need of services from 200 in 2002, the second year of operations, to approximately 800 in 2007 ( Fig. 1 ) (CARES annual report, unpublished data, 2007).
The mission of the CARES program is to improve oral health by decreasing barriers to care and improving access to dental treatment for special needs and difficult-to-reach patients. As such, CARES not only addresses the needs of patients in the dental clinic, but also fills a need of the school and its students. By helping patients to access treatment at the dental school, CARES social workers provide important clinic hours for students and help the clinic to generate income for the school. CARES staff also educate students about psychosocial issues that affect a patient’s ability to access care and teach dental students important skills in dentist–patient communication.
As stated above, the mission of a dental school is threefold: to educate dental professionals, to expand the knowledge base of the profession through basic and applied research, and to provide service to the community. This mission is paralleled by the roles of a social worker within a dental school as described by Levy: (1) education and training of dental professionals to improve their interactions with patients, (2) provision of social work clinical services to dental patients, and (3) research that can add to the body of knowledge on patient behaviors relevant to dental treatment.
From the beginning, the leadership in the SDM recognized that the CARES program served not only the needs of the patients, but also the institution. As a result, support for the program from the leadership in the SDM has remained strong despite the vicissitudes of state funding. This support at the top echelons of leadership in the SDM has been a significant factor in the success and longevity of the program. Without the financial commitment of the Dean’s office, it is doubtful that the program would have been able to continue to grow as it has.
CARES services
Typically, a dental student who is responsible for providing dental care refers a patient to the CARES program, although patients are referred through a variety of sources, including, word of mouth, community outreach events, and other social service providers. Once a patient is referred to CARES, a master’s level social worker or MSW student intern will conduct a psychosocial assessment, exploring issues such as health, mental health, personal finances, transportation, and family concerns. Although the majority of referrals are made for financial reasons (ie, a patient is struggling to pay for needed dental care), difficulties in these other areas can present barriers to care, and these are often uncovered only after a thorough social work assessment. After identifying the barriers to dental care, social workers intervene to overcome the socioeconomic barriers and enable the patient to complete dental treatment.
Financial Problems
Financial concerns are responsible for an increasing number of CARES referrals. Approximately 90% of the referrals in 2007 were for financial reasons compared with only 57% in 2005. This may be in part because of a worsening economy as well as a shrinking social service net (CARES annual report, unpublished data, 2005 and 2007).
Interventions that have been used to help patients deal with financial barriers to care include:
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Donated Dental Services—a program in which the SDM donates $30,000 of dental treatment each year
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Medicaid Application—CARES social workers assess patient income and eligibility; Medicaid applications are available and social workers provide assistance in completing and returning applications
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Community Resources—Financial assistance is available through a variety of community resources, including: heating assistance (HEAP), prescription assistance, grant opportunities, and programs such as food stamps and WIC. CARES social workers link patients with appropriate resources and assist with applications when necessary. Although none of these resources are targeted toward provision of dental treatment, receiving assistance toward food or heat may free up resources to pay for dental treatment.
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CARES Fundraisers and Donations—A limited amount of money is available for dental treatment through fundraising efforts such as raffles and through donations made directly to the program
Transportation
Patients who do not drive or cannot afford a car often experience difficulty with transportation, which contributes to missed appointments. CARES social workers link patients with community van services for seniors and individuals with disabilities (available in nearly every community in Western New York to enable them to attend appointments). CARES also provides bus and metro schedules and, in the rare instance in which a patient has been treated at the SDM and has no transportation to return home, CARES has provided emergency cab fare for the patient.
Mental Health Problems
Although mental health issues are the primary reason for referral for only about 10% of CARES patients, a significantly larger percentage of CARES patients suffer from mental health problems including: depression, anxiety, obsessive–compulsive disorder, schizophrenia, substance abuse, and suicidal ideation. CARES social workers intervene by:
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Educating dental providers and acting as a liaison and educator between the dental provider and the patient
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Offering reminders of upcoming dental appointments
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Providing linkage and referral to community mental health agencies, support groups, and individual counseling
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Providing coverage in the SDM in the rare event of a mental health emergency, or to de-escalate crisis situations with patients suffering from mental illness
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Providing psycho-education regarding relaxation techniques or other coping skills
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Offering counseling or emotional support beyond that which can be provided by dental providers
Other Health Problems
Because the aged and poor are over-represented in the dental school patient population, numerous SDM patients seek assistance from the CARES program regarding their health concerns. CARES social workers provide linkages to primary care physicians, specialists, and health care clinics. They also link patients with discount prescription plans; assist patients in prioritizing and managing oral and other health care needs; educate patients regarding the connections between oral health and overall health; and refer patients to community resources that specialize in physical health needs and disabilities.
Community Outreach
The CARES program has also played an important role in promoting oral health and access to care through community outreach. Social workers participate in events such as community health fairs and the Special Olympics as well as visiting agencies, such as senior centers, to educate community members about the importance of dental care and how community members can access dental care. One regular outreach event is the Lighthouse Clinic, a free medical clinic that is staffed by University at Buffalo medical students. Dental faculty and residents also offer free dental screenings at the clinic, and CARES social workers provide patients with linkage to an appropriate dental home. Through this clinic over a course of 21 months, 80 patients consulted with a social worker, 63 of whom were referred to a community dental provider and 17 of whom became patients at the SDM.
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