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Allan J. Formicola, DDS, Marguerite Ro, DrPH, Stephen Marshall, DDS, MPH, Daniel Derksen, MD, Wayne Powell, MA, Lisa Hartsock, MPH and Henrie M. Treadwell, PhD

Allan J. Formicola is with the Center for Community Health Partnerships, Marguerite Ro is with the Center for Community Health Partnerships and the School of Dental and Oral Surgery, and Stephen Marshall is with the School of Dental and Oral Surgery, Columbia University, New York, NY. Daniel Derksen and Wayne Powell are with the Center for Community Partnerships, University of New Mexico, Albuquerque; Daniel Derksen is also with the Department of Family and Community Medicine. Lisa Hartsock is with FirstHealth of the Carolinas, Inc, Pinehurst, NC. Henrie M. Treadwell is with the National Center for Primary Care, Morehouse School of Medicine, Atlanta, Ga.

Correspondence: Requests for reprints should be sent to Marguerite Ro, DrPH, School of Dental and Oral Surgery, Columbia University, 154 Haven Ave, 1st Floor, New York, NY 10032 (e-mail: mr965{at}columbia.edu).

	INTRODUCTION

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
The mission of the W. K. Kellogg Foundation’s Community Voices initiative is to improve access to primary, behavioral, and oral health care for uninsured and underserved populations. Poor access to dental services and growing racial/ethnic disparities in oral health demand new interventions and models of delivery.¹ Oral health is a core component of all 13 Community Voices "learning laboratories." Three of these programs—Northern Manhattan’s Community DentCare, New Mexico’s Health Commons, and North Carolina’s FirstHealth—provide innovative partnership models that seek to address some of our nation’s most pressing oral health care needs.

	NORTHERN MANHATTAN: COMMUNITY DENTCARE MODEL

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
Poor oral health was identified as the number one health complaint in a 1992–1994 population-based survey of Central Harlem adults.² In response, the Columbia University School of Dental and Oral Surgery, working in partnership with community-based organizations, devised and implemented the Community DentCare Network.³ Three linked community-based dental programs provide oral health care access to residents of Northern Manhattan across the life span, from children in the Head Start program to the elderly. The Community DentCare delivery system provides preventive and comprehensive treatment from fixed and mobile facilities, regardless of patients’ ability to pay for services. The 3 major components of the Community DentCare Network are 7 public middle school–based dental programs; 1 mobile dental clinic to reach the Head Start population during the school year and the elderly population during the summer; and 4 community health center sites offering comprehensive dental services.

Dental examinations revealed higher rates of dental caries in Northern Manhattan schoolchildren than in African American and Hispanic schoolchildren nationwide.⁴ The Community DentCare Network recorded 50 000 patient visits last year and provided 7000 school children with critical preventive dental services (including sealants) and dental treatment. Follow-up studies are needed to determine how effective Community DentCare has been in reducing oral health disparities for Northern Manhattan residents.

	NEW MEXICO: THE "HEALTH COMMONS" MODEL

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
Access to oral health services in New Mexico is poor and getting worse. Nationally, New Mexico ranks 49th in dentists per capita, 50th in child poverty, and 1st in the percentage of its population that is uninsured. In response to this oral health crisis, New Mexico Community Voices has been piloting and disseminating its "health commons" model.⁵

This community partnership model of enhanced primary care includes medical, behavioral, social, public health, and oral health services. It focuses on improving access to and quality of care for New Mexico’s underserved populations. Many of the intractable health problems in New Mexico’s communities are the consequences of historic, social, and economic factors. Such issues cannot be addressed adequately by a single health provider group or even by the health sector as a whole. Better solutions emerge when different sectors of society, including government agencies, educational institutions, businesses, and public and private stakeholders, collaborate rather than compete. Integrating key health services and community resources results in improved quality, efficiency, and capacity.

The cornerstones of the health commons model are the neighborhood care sites that serve as the safety net for the uninsured and underinsured. At these centers, medical, behavioral, social, public health, and oral health services are colocated. But colocating services is only the initial step in implementing an interdisciplinary, holistic approach to health care delivery. Many oral health patients have comorbidities such as diabetes and depression, in addition to social, language, and economic barriers to care. Each component of health care delivery (medical, behavioral, and dental) improves with better coordination of services and information.

In the health commons model, patient-centered oral health care is delivered by an interdisciplinary team. Depending on the client’s needs, the service providers may include a primary care physician or provider, a dentist or dental hygienist, a nurse or nurse’s assistant, a social worker, or a community health worker. The health commons safety net sites receive reengineering training enabling all members to function as a patient-centered, interdisciplinary team. The health commons model embraces health professions students and resident trainees as integral members of these interdisciplinary teams.

The University of New Mexico (UNM) Health Sciences Center is the state’s only academic health center. It provides critical safety net services and trains future health providers. For example, 40% of the state’s actively practicing physicians were trained at UNM during medical school or residency. While New Mexico lacks a dental school, UNM already trains dental hygienists and just received approval to begin a dental residency program. With support from the W. K. Kellogg Foundation’s Community Voices Initiative, the UNM School of Medicine’s Department of Surgery greatly expanded the capacity of the Division of Dental Services. While the institution had no dentists on the faculty at the start of the program, it now has 8. Its capacity has grown to include a 4-chair dental clinic at UNM, a referral system for dental emergencies arriving at the emergency department, the newly approved dental residency program, and outreach dental services throughout the state. Over the past year, UNM dentists and dental hygienists have provided care to more than 23 600 adults and children at community-based health clinics, federally qualified health centers, and university-operated sites.

	THE FIRSTHEALTH MODEL

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
Hoke, Montgomery, and Moore counties in North Carolina have 12 000 medically underserved children without health care coverage or access to dental care. FirstHealth of the Carolinas, a private, not-for-profit health care network, strives to meet the comprehensive health care and dental needs of all residents of the mid-Carolinas. In a dental needs assessment, oral health care was cited as the number one unmet need for low-income children in the region, but only 10% of dentists participated in publicly assisted programs. Few Medicaid patients were being seen, yet dental care providers were already working at capacity. The shortage of providers was especially acute for pediatric dental services.

Accordingly, FirstHealth developed an integrated model of dental service delivery. An oral health task force was created to identify strategies to address the oral health crisis. The task force prioritized improving access for children through a public model based on a private practice setting. With support from the W. K. Kellogg Foundation and local philanthropies, including the Duke Endowment and the Kate B. Reynolds Charitable Trust, FirstHealth opened a community-based dental care center in each of the 3 counties in the region.

Two of the 3 dental care centers use existing medical centers as their home sites, and the third operates in a newly constructed facility. These dental care centers provide comprehensive dental care for more than 7000 children, or nearly 60% of the targeted underserved population. By ensuring that all children who are eligible for insurance coverage are enrolled in Medicaid or other programs, FirstHealth proactively assists the financial sustainability of its dental care centers. In addition, children and their families can access other health benefits through the program and delivery sites.

	CRUCIAL ELEMENTS FOR STRENGTHENING THE ORAL HEALTH SAFETY NET

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
The common core elements of these 3 successful models are (1) involving the community in planning and implementation, (2) building upon the existing health safety net to link dental services with primary care, and (3) changing public or institutional policy to support the financing and delivery of dental care.

At all 3 sites, community support and involvement have been critical to building the political will and resources for the development of these dental programs. In each region (Northern Manhattan, New Mexico, mid-Carolinas), a committee, council, or task force was created to build consensus on the problems and potential solutions. Because they involve providers, educators, community members, and policymakers, these 3 models are community-based, linked to primary care, and integrated with needed social services. In building upon the existing infrastructure of safety net services, information and data systems, and health provider capacities (both medical and dental), each model integrates oral health into primary care services, thus improving the efficiency of both medical and dental services.

These collaborative efforts are helping to sustain the delivery of critical services while longer-term strategies are developed to improve access to oral health care and reduce oral health disparities. These longer-term strategies include surmounting the shortage of dental providers in underserved communities, increasing the diversity of the health professions workforce, and balancing the financing of health care to cover early prevention and health promotion as well as treatment of existing disease.

Improving access to oral health care and reducing disparities in oral health requires both institutional and health policy changes. Health service fragmentation creates formidable barriers. Using existing health care providers—pediatricians, family physicians, emergency room physicians, dental hygienists—where there are dental provider shortages can help strengthen the oral health safety net. While 44 million Americans have no health insurance, 100 million have no dental coverage. Most uninsured and underserved populations rely on Medicaid, yet states are cutting budgets and eliminating dental benefits. Thus, collaborative models such as those presented here may be the most cost-efficient and high-quality way to assure access to oral health services. Coverage of dental services and adequate reimbursement rates will help improve access to care for underserved and uninsured populations.

	SCALING UP COMMUNITY-BASED DENTAL CARE MODELS

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
A perplexing dichotomy currently exists. A National Call to Action to Promote Oral Health exhorts the dental profession and community-based clinics to take action to improve access to dental care in the United States.⁶ On the other hand, state governments—desperate to get their budget deficits under control—are cutting adult dental benefits from their Medicaid programs. Models offering basic oral health services in connection with community-based primary care services may ensure holistic, comprehensive health care for our most vulnerable and underserved populations.

	Acknowledgments

 
This work was supported by grants from the W. K. Kellogg Foundation’s Community Voices Initiative and is managed by the National Center for Primary Care at Morehouse School of Medicine.

Accepted for publication January 21, 2004.

	References

TOP INTRODUCTION NORTHERN MANHATTAN: COMMUNITY... NEW MEXICO: THE "HEALTH... THE FIRSTHEALTH MODEL CRUCIAL ELEMENTS FOR... SCALING UP COMMUNITY-BASED... References

 
1. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research; 2000.

2. Zabos GP, Northridge ME, Ro MJ, et al. Lack of oral health care for adults in Harlem: a hidden crisis. Am J Public Health. 2002:92:49–52.[Abstract/Free Full Text]

3. Marshall S, Formicola A, McIntosh J. Columbia University’s Community Dental Program as a framework for education. J Dent Educ. 1999, 6312: 944–947.

4. Mitchell DA, Ahluwalia KP, Albert DA, et al. Dental caries experience in northern Manhattan adolescents. J Public Health Dent. 2003;63:189–194.[Medline]

5. Beetstra S, Derksen D, Ro M, Powell W, Fry DE, Kaufman A. A "health commons" approach to oral health for low-income populations in a rural state. Am J Public Health. 2002:92:12–13[Abstract/Free Full Text]

6. A National Call To Action To Promote Oral Health. Rockville, Md: National Institute of Dental and Craniofacial Research; May 2003. NIH publication 03-5303.

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This Article Extract Full Text (PDF) Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Formicola, A. J. Articles by Treadwell, H. M. Search for Related Content PubMed PubMed Citation Articles by Formicola, A. J. Articles by Treadwell, H. M. Related Collections Community Health Dental/Oral Health Other Health Financing Health Policy Other Race/Ethnicity Socioeconomic Factors