Although most dental problems are highly preventable, limited access to dental care contributes to high rates of dental disease in children, particularly those in low-income and minority families. Beyond causing pain and discomfort, dental disease can affect children's overall health, as well as educational and social status. A lack of preventive dental care can also drive up the subsequent utilization and cost of dental services - with implications for payers, dental providers, and patients.
In New Jersey, the state's Medicaid managed care program, NJ FamilyCare/ Medicaid, provides dental care for children as a covered benefit, but statewide, only 22% of all eligible children ages 1-5 received any dental service in 2007, and only 20% received preventive dental care. The lowest rates of preventive care were in those under age 3.1
To improve access to oral health services for New Jersey's low-income children, the Center for Health Care Strategies (CHCS) partnered with key stakeholders to develop New Jersey Smiles: A Medicaid Quality Collaborative to Improve Oral Health in Young Kids (NJ Smiles). NJ Smiles, made possible by the Robert Wood Johnson Foundation, involved New Jersey's Medicaid managed care organizations (MCOs) - AmeriChoice of NJ, AMERIGROUP NJ, Health Net, Horizon NJ Health and University Health Plans; the New Jersey Medicaid agency; New Jersey Head Start; and other regional partners. Launched in 2007, the 18-month collaborative effort sought to:
"The sooner a child receives dental care, the less likely he or she is to experience acute dental disease, which is costly in terms of resources and quality of life for the child," explained Brian Bastecki, DMD, dental director for NJ Smiles participant Horizon NJ Health, New Jersey's largest Medicaid MCO. "Untreated dental problems are harbingers of a disease process that can be very dangerous - a tooth abscess, for example, can become a life-threatening, systemic infection. A person with an unhealthy mouth is not healthy."
NJ Smiles identified the Head Start programs in the city of Newark, which served more than 2,000 high-risk children ages 0-5 and their families - as an opportune setting to promote better oral health care. The decision to implement a "high-touch" strategy through these sites was based on a number of factors, including Head Start's mandate to provide a dental home for enrolled children; accessibility to pediatric oral health resources through the University of Medicine and Dentistry of New Jersey and other dental providers; and Head Start's relationships with local dentists. Furthermore, Newark Head Start children and their families, 95% of whom are NJ FamilyCare/ Medicaid-eligible, are an already-engaged audience for receiving oral health education and care.
"While most Head Start children are eligible for insurance coverage for a dental exam, NJ FamilyCare/Medicaid dental encounter claims data revealed low utilization of services," said Bonnie Stanley, DDS, chief of Dental Services, New Jersey Division of Medical Assistance and Health Services (DMAHS). "Partnering with Head Start allowed us to improve oral health practices among the youngest, low-income children, who offer the biggest opportunity for improving prevention of dental disease."
NJ Smiles pursued three key activities to improve pediatric dental access in Newark. Based on a survey of and face-to-face meetings with dentists participating with NJ FamilyCare/Medicaid, the collaborative created the NJ Smiles Directory of Dental Providers for Children. This resource lists New Jersey pediatric and general dentists who participate with Medicaid and are willing to see young children. The directory was sent to pediatric primary care providers (PCPs) and Head Start sites to facilitate dental referrals. Subsequently, staff from the MCOs met with Newark-based PCPs and their office staff to reinforce the importance of oral health to overall health, and to encourage screening, assessment, and dental referrals.
Secondly, NJ Smiles engaged dental providers in Newark to deliver screening services at Head Start sites; to provide office-based, preventive and follow-up treatment; and to serve as dental homes for Head Start students. This was encouraged through outreach phone calls from Dr. Stanley and dental directors of the participating MCOs, and the provision of mechanisms for specialty care referrals, a critical element for general dentist participation.
"Prevention and education are what make a difference in the oral health of young children and their families," explained Lezli Harvell, DMD, a participating NJ Smiles pediatric dentist. "My practice's concept of a dental home begins with educating families about the importance of oral health to overall health. At Dental Kidz, we routinely measure children's body mass index and teach families about nutrition, the obesity epidemic, and good oral health habits."
Lastly, NJ Smiles produced A Guide to Improving Children's Oral Health Care: Tools for the Head Start Community. This toolkit supports Head Start staff in working with students, families, and community dental providers to monitor, document, and improve children's preventive dental care. It includes action steps for confirming NJ FamilyCare/ Medicaid enrollment; identifying a family's MCO; establishing routine dental care; practicing recommended oral health behaviors; and educating families about screening and prevention.
The 18-month NJ Smiles effort far-exceeded its goals based on completed dental visits and the establishment of dental homes for the target population. Encounter data reported by participating MCOs showed that approximately 36% of Newark children (ages 0-5) in Medicaid managed care had an annual dental visit by the program's completion, compared to 30% at baseline.5 The youngest children had the lowest baseline rates, as well as the greatest relative improvements: rates in those under age 2 increased from 5% to 13%, and in those ages 24 to 36 months, from 18% to 30%. Similar results were seen across the program's six target cities.2
Furthermore, self-reported data from the Newark Pre-School Council, an NJ Smiles participant that oversees 46 Head Start sites in the city, showed that 96% of its students had an established dental home in 2008 following the intervention.3 In comparison, only 78% of Head Start children statewide had access to a dental home in 2007,4 suggesting the significant impact of the program's high-touch approach in Newark.
Members of the collaborative cite many factors behind its success, including provider commitment. "The caries rate in preschool children has increased, piquing the dental community's interest in prevention efforts for young children," explained Dr. Bastecki. "In addition, primary care providers really responded to our outreach and committed to educating families about the connection between oral health and overall health."
Dr. Bastecki also noted the appeal to the MCOs. "In New Jersey, there is no single payer of Medicaid health services, but five MCO and fee-for-service plans. By nature, we were working in silos, but the scope of the problem called for collaboration. The NJ Smiles workgroup provided a forum for partnership."
Dr. Stanley cited collaboration and communication among plans, providers, and Head Start representatives as critical to addressing low utilization. "We brought everyone around one table to dispel myths and misunderstandings related to NJ FamilyCare/ Medicaid enrollment and covered benefits," she added.
Suzanne Burnette, director, New Jersey Head State Collaboration Project, pointed to the "empowerment" of Head Start staff as a significant factor behind program outcomes. "As a result of the resources and support they were given, they felt able and motivated to work directly with the MCOs and the dentists in their communities," she explained. "The collaborative's education of MCOs and providers about Head Start regulations, data collection challenges, and 'culture' was critical, as well."
While the collaborative exceeded its goals, further improvements in utilization of diagnostic and preventive oral health care among New Jersey's low-income children are still needed. As Newark Head Start programs increasingly adopt the oral health education and promotion strategies supported by NJ Smiles, the initiative's impact on utilization and related outcomes is expected to grow.
Leaders in the NJ Smiles collaborative hope to advance these goals by collaborating with the American Academy of Pediatric Dentistry (AAPD) Head Start Dental Home Initiative in New Jersey.6 AAPD and the national Office of Head Start launched the national initiative in 2008 to develop a nationwide network of dentists to serve as dental homes for Head Start children. Its expansion into New Jersey, scheduled for May 2010, will support the current partnership between NJ FamilyCare/ Medicaid MCOs and Head Start; training for Head Start staff and families in use of the NJ Smiles oral health toolkit; and links between community "champion" dentists and Head Start sites.
1 Division of Medical Assistance and Health Services, State of New Jersey (March 2008). CMS-416: Annual EPSDT Participation Report.
2 Note: Dental visits were measured using specifications from the HEDIS® 2008 Annual Dental Measure, and pertained to children residing in Newark (though not necessarily enrolled in Head Start). The rate may under-represent actual dental visit completion, as many providers report that they did not submit claims to the MCOs for Head Start children.
3 Note: Across the program's six target cities, the percentage of children in Medicaid managed care with an annual dental visit increased from 31% in 2007 to 37% in 2008; the greatest increases were seen in children under age 3. More substantial year-one (2007-2008) increases were not seen in Newark compared to the other five participating cities due to delays in Head Start implementation of quality improvement strategies.
4 Note: The rate of dental home establishment (96%) is for children enrolled in the Newark Pre-School Council program, while the rate of dental visits (36%) is for all Newark children ages 0-5 who are enrolled in managed care.
5 Center for Law and Social Policy (2009). New Jersey: Head Start by the Numbers: 2007 PIR Profile.
6 For more information about the AAPD Dental Home Initiative, visit http://www.aapd.org/advocacy/dentalhome/.