A robust oral health workforce is essential to improving access to oral health care for Medicaid members, particularly those in historically underserved communities. Rhode Island, however, like many states, has faced significant oral health workforce shortages for years. To support workforce expansion and sustainability, the Rhode Island Oral Health Coalition (RIOHC) and Rhode Island Department of Health (RIDOH) Oral Health Program released a Dental Workforce Strategic Plan in July 2024 outlining key priorities, strategies, and metric goals to strengthen the state’s oral health workforce.
The Center for Health Care Strategies (CHCS) spoke with Samuel Zwetchkenbaum, DDS, MPH, Dental Director of RIDOH and Executive Office of Health and Human Services (EOHHS), Rick Brooks, Director of Health Workforce Transformation at EOHHS, and Monika Drogosz, Interim Program Manager and Epidemiologist in the Oral Health Program at RIDOH, to learn about their experience developing the state’s Dental Workforce Strategic Plan. Rhode Island was one of 11 states that participated in CHCS’ Medicaid Oral Health Workforce Implementation Learning Series, made possible through support from CareQuest Institute for Oral Health.
Strengthening the Oral Health Workforce Through State Oral Health Improvement Plans
While Rhode Island developed a targeted framework to improve its dental workforce, many states embed workforce strategies within broader State Oral Health Improvement Plans (SOHIPs). This tool highlights how states across the U.S. have used SOHIPs to address workforce development, summarizing each state’s priorities, objectives, and strategies for sustaining a strong oral health workforce.
Q: What are the key challenges Rhode Island faced with its oral health workforce?
R. Brooks: Even before COVID-19, Rhode Island was experiencing oral health workforce shortages, and those pressures only got worse during the pandemic as people left the field, decided not to go into health care occupations, or cut back their hours due to burnout and stress. Resulting challenges included worker shortages, a lack of diversity among health care professionals, high turnover, and limited awareness of the different health care occupations available to students. The access and quality challenges that result from these workforce shortages are even more pronounced in Medicaid, as we not only lack enough providers overall, but we also don’t have enough providers who serve Medicaid beneficiaries, either by choice or by geographic inaccessibility.
Q. How did Rhode Island work with partners to address these challenges?
R. Brooks: EOHHS brought together state agency and private sector partners — including higher education, provider organizations, professional associations, trade associations, labor unions, community-based organizations, advocacy organizations, and anybody else with an interest in health care and health care workforce — to address the issues our state faced. From a Medicaid perspective, access translates into recruitment, retention, supply, cultural competence, and all the different pieces that are essential for supporting our Medicaid beneficiaries. To address this, we’ve done cross-training and raised awareness about the importance of having public health dentists and public health dental hygienists. We’ve been able to make connections across the many intersections of oral health, such as behavioral health and community health workers. Integrating oral health care into various physical health services has been made possible through these connections. We also launched initiatives to support the training of dental assistants in collaboration with health centers, attracting individuals representative of the population served and who otherwise may not have pursued a dental career.
Q: What was the impetus for developing an oral health workforce-focused strategic action plan?
S. Zwetchkenbaum: Rhode Island has a limited number of dental professionals. This is exacerbated by the lack of an in-state dental school, an aging workforce, and limited educational pathways for dental professionals. We needed a plan to address the downward trend in the oral health workforce and promote opportunities for advancement within communities that represent Rhode Island’s socioeconomic and racially diverse landscape.
It’s a small state, and we get to hear directly from our providers, who consistently reported on challenges recruiting dentists and not having enough dental assistants. We knew this was directly impacting patients’ ability to get an appointment, and that was a big impetus.
Another factor was receiving a Health Resources and Services Administration (HRSA) workforce grant that allowed us to bring on Health Resources in Action (HRIA) to help us develop our strategic action plan. HRSA’s goal with this funding is to support initiatives that strengthen the health care workforce, improve access to care in underserved areas, and enhance training and education for health professionals.
Q: How did you engage stakeholders in the strategic planning process?
S. Zwetchkenbaum: In 2023, the theme of our annual mini-residency was dental workforce, and we had some great presentations and breakout sessions. The mini-residency consisted of dedicated conversations with dental assistants, dental hygienists, and dentists to discuss new ways to recruit and sustain a dentistry workforce. It was interesting to see what each viewed as challenges and solutions, and we found that there were indeed differences. Rhode Island’s only dental education program, housed at Community College of Rhode Island (CCRI), also participated. Our goal was broad and active participation to discuss everyone’s varying priorities, which was challenging but important. We wanted every stakeholder to be involved in the strategic plan development process.
Q: What type of data did you gather to inform your recommendations, and what did the plan development process look like?
S. Zwetchkenbaum: We gathered quantitative and qualitative data, including insights from the dental mini-residency, HRIA’s stakeholder survey of oral health associations, key informant interviews, and the Health Workforce Data Dashboard, which provides the number of licensed individuals and demographic details, such as race and ethnicity. These data points informed our priority areas: (1) recruitment; (2) retention; (3) workforce education; (4) training; and (5) policy development. Working in breakout sessions during the mini-residency, each group focused on one priority area to develop goals, then rotated to review and provide feedback on other groups’ work. Subsequent sessions established objectives, strategic activities, and success measures. These measures now serve as guiding lights for implementation and progress tracking of our efforts and programming.
Having the HRSA funding to work with supporting organizations helped sustain the work and get many stakeholders involved — which is important and a challenge to coordinate and promote engagement. But being on the other side of that work, we’re ready to go forth with those strategic activities, bring people back into our workforce, and keep them involved.
Q: Beyond the strategic plan, in what ways has the HRSA workforce grant contributed to advancing oral health initiatives in the state of Rhode Island?
M. Drogosz: We’ve had the HRSA Workforce Grant since 2022, and we’re entering our last year. It’s helped us create innovative programs that have expanded the oral health workforce. For example, we’ve been supporting a dental assistant program through East Providence High School’s career technical program.
We’ve supported dental externs through Rhode Island’s federally qualified health centers to provide much-needed patient care and expose students to these settings as a career option. The idea is to bring in out-of-state students and hopefully have them return to stay in Rhode Island. We work closely to support this dental externship program and conduct evaluations to better understand driving factors for students to practice in Rhode Island. At least three dental externs have been hired full-time, which is great! We’ve been tracking the dental assistant program to see how many graduates go on to work professionally or pursue different educational opportunities in dentistry.
The grant also provided funding for us to be part of Project ECHO. We’re on our third ECHO series, focused on special care dentistry. One institution, in particular, the Sinclair Dental Center at Rhode Island Hospital, has capacity limitations and long wait times. It’s one of the only institutions in the state that takes patients with special care needs. The goal through Project ECHO is to get more dentists in the community to provide preventive care for this population so patients don’t always have to go into the hospital for basic things.
These initiatives have created educational opportunities and promoted advancement, and the grant has built upon RIDOH’s priorities: improving the retention of dentists, training and retaining more dental assistants, and ensuring that all dentists in the state have access to continued education.
Q: Is there any advice you would like to share with states considering developing a workforce-specific oral health strategic plan?
S. Zwetchkenbaum: It is important to develop a team of stakeholders, including members involved in different aspects of the dental workforce, and aim for some early wins. Those who have been part of the state’s oral health coalition, the annual Mission of Mercy, and the dental mini-residency, for example, are more likely to have sustained involvement through the process than those who have just started getting involved through the strategic plan. We have also found it beneficial to develop regular reports to share updates on data and new successes.
