In 2010, an estimated 70% of Americans nationwide visited the dentist or dental clinic. However, the number of dental visits reported is substantially less for low-income individuals.
The rate of dental visits for Americans with an income of $15,000 or less was 46% in 2010. Along with poverty, other barriers to dental care include lack of insurance, no established relationship with a primary care provider, and dental provider shortages. In the state of Missouri, only 29% of individuals with an income of $15,000 or less went to a dentist or dental clinic in 2010.
Although income-based data for St. Louis City and County are not available, under- and uninsured populations in the St. Louis community are similarly shown to struggle with access to dental care. This is especially true as dental services for adults are not currently covered by the Missouri Medicaid Program.
Improving access to dental services for the under- and uninsured was identified as an important priority area of the St. Louis Regional Health Commission (RHC) in its 2003 Building A Healthier St. Louis Report.
As an outcome of the report, the RHC approved the following resolution for the allocation of dental services on November 17, 2009:
“An allocation of no more than $1,035,000 in aggregate to support those Integrated Health Network (IHN) members located in St. Louis City or County that successfully demonstrate proof of expansion of dentistry services by at least one dentist with necessary support staff and supplies for one year, with a total maximum allocation of $207,000 for each individual community health center.”
The allocation allowed for the creation of the RHC Dental Grant Initiative. The initiative provided funds to grant awardees to hire at least one dentist with necessary support staff and supplies for one year, beginning in 2011.
Initiative objectives included:
- Increase access to dental services for the underserved at community health centers (CHCs) by +2000 visits per awardee institution over 2010 volumes that is to be sustained post-initiative.
- Increase CHCs’ capacity to provide dental services to underserved populations.
- Assist with start-up costs associated with hiring a new dentist and support staff.
Eligibility for initiative support was limited to CHCs that provide a majority of services to residents of St. Louis City and County. Candidates had to demonstrate proof of expansion capacity for dentistry services, and/or provide a detailed and feasible plan for expansion capacity, beyond the one-year grant funding period. Applications underwent extensive panel review by health providers and local community health experts designated by the RHC.
Five CHCs applied for initiative support. Three were awarded the maximum amount of $207,000 for a one-year period in 2011, including:
- Betty Jean Kerr People’s Health Centers (BJK People’s)
- Family Care Health Centers (Family Care)
- Grace Hill Neighborhood Health Centers (Grace Hill)
St. Louis County Department of Health (STL County) was also given a maximum grant, which began in August 2012 shortly after the opening of the new John C. Murphy Community Health Center. Data reporting below is based on the three institutions that began their grant funding in 2011.
- Nearly all awardee institutions met the objective of 2000 plus dental visits over the grant year (refer to Figure 1).
- BJK People’s: approximately 38% increase in dental encounters (+4858 visits)
- Family Care: approximately 17% increase in dental encounters (+1169 visits)
- Grace Hill: approximately 23% increase in dental encounters (+4681 visits)
- 50,647 dental visits were provided among the three CHCs during the grant year, in comparison to 39,939 dental encounters over calendar year 2010 volumes.
- 27% increase in dental visits from 2010 to 2011 (+10,708 total visits)
- Each grant-supported dentist provided a significant number of dental visits over the course of the grant year (refer to Figure 2).
- BJK People’s: 1,726 dental encounters
- Family Care: 1,416 dental encounters
- Grace Hill: 2,678 dental encounters
- Dental full time employee counts remained stable during the grant year.
- Positive response from patients and staff at all three awardee institutions.
Challenges and Solution Strategies
Challenges experienced by grantees included variable difficulty with recruiting new dentist and support staff and a high no-show appointment rate. To address the recruitment challenge, grantees requested and were given an extension on the grant if necessary to allow sufficient time to recruit a new dentist and support staff. In response to the high no-show rate, awardee institutions adjusted provider protocols to reduce the number of exit appointments and implemented additional reminder calls prior to appointments.
Preliminary follow-up of initiative outcomes suggests that increased capacity has been sustained six months post-initiative. In addition, dental FTE counts have remained stable, and the grant-supported dentist at each awardee institution has integrated well into the workflow. The annual incremental cost of dental expansion is projected to be minimal over time. Each institution intends to sustain the additional costs for dental service expansion from patient revenues.
In addition, on July 1, 2012 the Gateway to Better Health program was implemented at community health centers across the St. Louis region, including BJK People’s, Family Care, and Grace Hill Health Centers. Gateway to Better Health is a healthcare program for eligible uninsured adults between the ages of 19 to 64 years who are residents of St. Louis City and County. Among a variety of other preventative, primary, specialty, and urgent care services, this program covers dental care. This program, currently set to be in place through December 31, 2013, will serve as an additional mechanism to help sustain and increase dental capacity at all grantee sites.
In 2011, local CHCs were able to provide nearly 6,000 additional dental care visits to underserved patients that would not have received services otherwise. Three CHCs were able to expand the capacity of their dental programs in 2011; preliminary follow-up suggests that capacity increase has been sustained post-initiative.
Funding for new dentists, with the necessary support staff and supplies, considerably increased access to dental care among the underserved in St. Louis City and County.
Additional evaluation of the RHC Dental Grant Initiative is needed to assess its long-term viability as a sustainable approach to increase access to dental care services for patient populations in need and to size the remaining unmet need for dental services in the region.