Madeline Pucciarello, MPH

December 18, 2018

Primary care professionals are generally the first point of contact in the health care system and are often underutilized as a source of basic oral health services to their patients. Fluoride varnish application, one of these services, is an evidence-based approach to preventing and controlling tooth decay in children. In Louisiana, Brandon Bueche, Medicaid Dental Program Director for the Louisiana Department of Health (LDH), and MeChaune Butler, Oral Health Program Manager for the Office of Public Health, are working to address this gap through an innovative approach to increasing the utilization of pediatric fluoride varnish services in their state.

CHCS recently spoke with Ms. Butler and Mr. Bueche — both recent fellows of CHCS’ State Oral Health Leadership Institute (SOHLI) funded by the DentaQuest Foundation — who shared their approach to integrating fluoride varnish into primary care services for children enrolled in Medicaid.

Q: You hope to increase fluoride varnish utilization by increasing primary care provider participation in Louisiana’s Professional Services Fluoride Varnish Program.  How did this project start, and why is it important to your state?

Brandon and I had an interest in fluoride varnish because it is an evidence-based practice with great value, and our fluoride varnish utilization numbers have been relatively low.

A: M. Butler: Brandon and I both had an interest in fluoride varnish because it is an evidence-based practice with great value, and our fluoride varnish utilization numbers have been relatively low. In 2011, the state established the Professional Services Fluoride Varnish Program Policy enabling non-dental professionals to apply fluoride varnish in the physician’s office. However, there was no education or push for providers to deliver the service. When Brandon and I talked about Medicaid and oral health priorities, we both agreed that fluoride varnish application within non-dental offices was something that needed to be a priority. We wanted to work with our managed care organizations (MCOs) because they have strong connection to and ability to educate providers and get them certified to apply fluoride varnish in their practices.

A: B. Bueche: Across the state, we have 1,025 water systems, serving over 4.7 million residents, and only 122 of those systems are fluoridated, so this topic is important to both our agencies within the LDH, and it’s important to the children of Louisiana. We also wanted to raise awareness of oral health in a physical health setting by promoting our existing fluoride varnish policy and increasing referrals to primary care dentist by pediatricians as a part of the process. Pediatricians are important because they often see young patients who are not being seen by a dentist.  They are able to apply fluoride varnish and be reimbursed by the Medicaid program, perform an initial oral health screening, and make a referral to a primary care dentist in the local area.

Our dental contractor had an innovative program in Florida, and we hoped to replicate the results it achieved there in Louisiana. Our dental benefit plan manager provided custom printed referral “tear-off” pads to each participating pediatric office with a list of dentists in close proximity accepting new patients and also informed those dentists about the program.

Q: Integrating oral health and physical health is often seen as a challenge, but your work highlights the importance of connecting physical and oral health care. How do your efforts strengthen this connection?

Folks think about chronic disease as it relates to diabetes, tobacco, etc. but not oral health. It’s important for us to show the connection and not be dismissed.

A: M. Butler: We know that oral health touches everyone’s life and is a part of overall health. My unit is housed within Chronic Disease Prevention and Health Promotion, but tends to be the stepchild. Folks think about chronic disease as it relates to diabetes, tobacco, etc. but not oral health. It’s important for us to show the connection and not be dismissed. This is one of the reasons we chose to focus on fluoride varnish; it gave us an opportunity to interact with the medical community.

A: B. Bueche: We have five MCOs delivering physical health care to our members and a single statewide dental benefit program manager for oral health. Our efforts strengthen the connection by bringing together a team from Medicaid, Office of Public Health, the dental benefit plan manager, and a representative from each of our five health plans, working toward the same goal. The project also raises awareness of oral health in pediatric offices participating in the program by encouraging the application of fluoride varnish and referrals to dentists in the surrounding area.

Q: Through this project you’ve worked with many internal and external stakeholders. What have you learned about how to engage and work effectively with partners?

A: B. Bueche: We learned early on to be very clear in our messaging. We didn’t expect any physician to be hesitant about participation. What we didn’t realize was that our message wasn’t clear about what we were trying to accomplish. We learned that we needed a concise message in order to be effective.

At the start of our work, we had a goal of identifying at least two pediatric offices per MCO. We have 11 that have agreed so far to participate. We’re in the process of integrating some of these offices into the program, so we have not yet expanded it, but we have an identified contact within each MCO to reach out to as soon as we’re ready to recruit more pediatric offices. Being intentional about creating these contacts at the start of our work has helped to ensure the sustainability of the program.

A: M. Butler: For me, I learned to always be prepared with information and be upfront about your needs whenever working with partners. I’ve also learned how cooperative and responsive our MCOs are. We provide the MCOs with various educational materials that they now use regularly. They also shared a one-page fact sheet with providers at the start of this work. They’re a great resource for us.

Q: How did your partnership contribute to your successes? What have you learned about successful partnerships between Medicaid and public health?

Public health has the programming, but we need Medicaid to build the foundation. We can’t do one without the other.

A: M. Butler: Brandon and I are extremely busy running different programs. To sustain our relationship, we have carved out the time and stayed committed to meeting regularly. Prior to this work, Medicaid was this place that I knew I needed to be connected to, but other than sending e-mails with requests, I was not connected. We both learned about the SOHLI fellowship and wanted to participate in order to sustainably build our working relationship. We’ve learned that our two organizations are very different but also alike. Public health has the programming, but we need Medicaid to build the foundation. We can’t do one without the other.

A: B. Bueche: This work was unlike any that had been done in the state before. This was a collaboration of multiple stakeholders, and there’s no way that one person could’ve done it alone. We make better progress as a team when we combine our resources. This includes program goals, policies, and personnel. We’re also now more aware of shared oral health goals and the benefits of regular collaboration.

Q: Do you have any advice for states looking to work with physical health partners to improve oral health?

A: B. Bueche: This work has shown me that it’s important to identify team players, as we are stronger together.  Also, we learned how key it is to have a plan and make sure our messaging is clear. Lastly, be persistent and don’t get discouraged. Sometimes it can take longer than expected to reach your goals.

A: M. Butler: Find opportunities to connect oral health into what’s already being done. It can be big or small, but you can start by looking for small opportunities. They can lead to the largest wins. No matter how small it is, it’s the fact that you’re collaborating that can catalyze change.


Related Reading

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Case Studies: Improving Oral Health through Cross-Agency Partnerships in Missouri and Rhode Island – These case studies, featuring success stories in Missouri and Rhode Island, illustrate how inter-agency and cross-sector partnerships can be used to increase oral health care utilization among low-income populations. Read more »

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