May 9, 2018
by Josie Costantiello, RDH
You would be hard pressed to find anyone in the dental industry who has said that starting a new mobile dental and/or dental hygiene practice in the community is an easy and simple feat. In fact, from the experiences of my own and other persistent dental hygienists, it is anything but easy and simple. Now, add to the “challenges” of operating a mobile practice with a patient base comprised of individuals with various special needs, factoring in behavioural and often at times logistical challenges, individuals with Autism Spectrum Disorder, Developmental Disabilities, Dual Diagnosis and individuals with severe mental health conditions.
Taking all of the above into account, it is quite understandable that for those dental providers who have not had the opportunity to expose themselves to this community group and method of practice, while training in school or during their own clinical work experience, this surely would sound like a recipe for disaster. The good news is, it has not been a disaster and slowly but surely, through the help of several individuals in the dental and special needs communities, systems and pathways have been created in order to better serve these individuals in obtaining access to compassionate, quality preventive dental care in familiar and comfortable surroundings, right in the comfort of their homes/group homes or day programs.
Let’s take a closer look at what I, and many other dental providers have encountered, as the main challenges for vulnerable persons who have had issues in accessing dental care in Ontario:
1. Lack of Proper/Adequate Provincial Funding: Provincial Government Subsidized Social Services Programs for individuals in the special needs community who are on General Disability Coverage and/or Low Income Social Services Coverage. The Dental Fee Guides associated with these Government Subsidized Programs, which reimburse dental providers for treating individuals who receive Social Services Assistance, provides two main obstacles in allowing this group access to adequate dental care.
a. Fees associated with the dental procedures in these Social Services fee guides are extremely low in relation to the Provincial Suggested Dental Fee guides provided by The Provincial Dental Associations (ie: ODA and ODHA) and are so outdated that they have not been updated in almost a decade. While the idea of subsidized funding is understood, the issue is that the fees behind this subsidization are so outdated that, unfortunately, it creates a stressful situation for dental providers who are dedicated to providing more frequent and comprehensive care for this demographic. The level of compensation from these government subsidized programs is out of touch with the reality of the current economic climate, and so it becomes extremely challenging for dental providers to be willing to accept patients on a regular basis. I personally have encountered many dental offices in the community who either do not accept Government Subsidized Social Assistance Dental Coverage at all, or some that will schedule only one person per month who receives this coverage. Some Government Subsidized Coverage Programs go as far, in the majority of regions in the province, to not even cover any preventive services at all, such as dental scaling, and will only cover dental emergencies, such as extractions and restorations, based on an “approval” basis. There is little to no incentive for dental providers to adequately book their schedules with patients who receive Government Subsidized Dental Coverage as many feel that they “lose money” given the high overhead and fixed expenses dental offices have in order to run their clinics from a long term business standpoint.
b. The administrative obstacles present within these Government Subsidized Dental Programs, although improved upon over the last few years, make it difficult to perform routine procedures more frequently on this populated demographic due to the constant necessity for pre-determinations/ “estimates”. Many dental offices have told me that the time it takes out of the dental administrative staff’s schedule to process and follow up with these estimates makes it inevitably “not worth it” from an overhead expense standpoint.
2. Misconception that mobile dental hygiene practices “take away” from dental clinics in the community is the next challenge: Speaking from experience, the present large gap that I have witnessed in accessing dental care with the individuals in this demographic in and of itself proves that dental clinics are having difficulties in coordinating access to dental care for these patients and hence, are presently not even treating their dental needs. In terms of the Mobile Dental Hygiene Preventative Service I provide, I not only work directly with dentists who assist in providing examinations, initial screenings and treatment planning for patients, prior to me performing my preventative services, but we also refer these patients, whom the majority have not accessed dental care for several years, to local community dental clinics and simplify the process for these clinics by targeting and treating the main areas of concerns without “tying” them up and becoming an economic burden in treating these patients. Dental clinics in the community become how specialty dental clinics are for general dentistry clinics. Special Needs patients are “prepped” and the treatment planned ahead of time before being referred directly to community clinics to continue the prescribed treatment plan.
3. The immense obstacles in forming a new relationship not only with the future special needs patients, but with their caregivers and/or group homes, need to be overcome first which can take several hours of patience, and administrative and clinical coordination (group homes can house from four to over 75 people under one roof, depending on the size of the home and the types of needs the individuals have). These obstacles include, but are not limited to:
The level of experience required in working with this group cannot be understated. Through my many hours and years working with this demographic I can honestly say that this type of mobile service may not be of benefit for a dental provider to “contract” out. It is imperative that dental providers who wish to become involved in treating this demographic invest time and resources in working with these patients directly, not only on a dental level but, on a volunteer basis in community clinics and group homes to truly get the “feel” for the constant struggles and difficulties in communicating with these individuals and gain valuable experiences in effectively communicating with them in order to perform dental treatment in a worthwhile manner. Further, from an economic standpoint, and based on the current Government Subsidized Dental Programs, in order to obtain not only critical treatment and personal satisfaction from treating these patients, but also economic satisfaction, it is important that dental providers perform the treatment directly themselves.
4. The next challenge is finding a local dental clinic for the patient to obtain dental radiographs, and any treatment required, nearest to their residence (a clinic that will accept Government Subsidized Dental Coverage). Annual dental radiographs is a strict policy to emphasize to patients, whereby it is constantly communicated to the patient that the initial diagnosis is “preliminary” and it identifies more obvious “problems”, and that a definitive diagnosis can only occur with dental radiographs performed at a dental clinic. The ongoing discussion of the importance of dental radiographs is the first step in “bridging” the gap for the patient to obtain more comprehensive dental treatment at local dental clinics. The ongoing encouragement to seek a more “thorough exam with x-rays” is discussed at each visit, once the dentist on our mobile staff has performed their complete exam/screening and formulated a preliminary diagnosis at the home. There is no doubt that the majority of the individuals residing in group homes have either never been to a clinic to see a dentist or go very infrequently, based on clinical findings with experience. It is the “nudge” that mobile dental clinicians give to these individuals or their care givers that will most likely result in a trip to the clinic where they are less likely to go on their own will. For those dental clinics who do accept Government Subsidized Dental Coverage, mobile clinics can only “add” to their patient base, not subtract from them.
From an advocacy standpoint, in an effort to support the elderly and persons of all ages with varying special needs, the Government of Ontario should take a more realistic approach to subsidizing dental care for these individuals. This includes not only improving upon the compensation levels in the existing government funded programs, to a point where it is in line with annual inflation and is no longer unsustainable economically to treat these patients in larger numbers and higher frequency, but also consider increasing the eligibility age for elderly individuals on the Government Subsidized Disability Program from 65 to at least 70 years of age. A great amount of low income elderly individuals have some form of disability, but due to the age restrictions of the existing Government Subsidized Disability Program, they no longer qualify (the age where many health problems, including oral health, deteriorate at a much faster rate). Simply providing a “tax credit” to “reimburse” individuals 12 months later, who do not have dental insurance, in order to possibly allow them to obtain emergency and more frequent dental care completely ignores the fact that the vast majority of these people struggle day-to-day to cover the costs of living never mind pay for dental care “upfront” and then get a tax credit 12 months later.
As the old saying goes, we as a society are judged on how we treat our most vulnerable. Can our past and current governments really say that they have treated the dental needs of our most vulnerable well and that they have made a concerted effort not to handicap the vast majority of dental providers who wish to provide dental care for the special needs population? The outcries of our veterans and families of persons with disabilities tend to say otherwise.
About the Author
Josie Costantiello, RDH has 10 years experience working as a Self-Initiated Dental Hygienist and dedicates the majority of her time treating individuals with various Special Needs, through her partnership in the company Community Outreach Mobile Dental and Dental Hygiene Services (COMDH). Josie works as a part time clinical instructor in the Dental Hygiene clinic at Durham College, where she graduated from in 2008, guiding the next generation of Dental Hygienists, in an instructional and mentorship capacity, in regards to their skills and development into future dental hygiene providers, with hopes that some may pursue careers within the Special Needs community. Josie has three family members with Special Needs, ranging from Down’s Syndrome, ASD and a rare genetic intellectual disability. Josie can be contacted through her website: www.comdh.org.