Local Dental Pilot Project Application - California ...€¦ · LIBERTY Dental Plan DHCS Contracted...

Local Dental Pilot Project Application

Application Due Date: September 30, 2016

Section 1: LDPP Lead Entity and Participating Entity Information

1.1 LDPP Lead Entity and Contact Person

Organization Name Sacramento County Department of Health and Human Services Division of Public Health

Type of Entity County County Entity1 City and County

Tribe Indian Health Program

UC or CSU campus

Consortium of counties serving a region consisting of more than one county

Contact Person Debra Payne, MSW

Title Sacramento County Public Health Program Planner

Telephone (916) 801-3301

Email Address [email protected]

Mailing Address Department of Health and Human Services 7001A East Parkway, Ste. 600 Sacramento, CA 95823

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1.2 Participating Entities

Organization Name and Address

Description of Organization

Contact Name, Title, Telephone and Email

Role in LDPP

1. Medi-Cal Dental Advisory Committee 2750 Gateway Oaks Drive, Ste. 330 Sacramento, CA 95833

Sacramento County Medi-Cal Dental Advisory Committee

Terrence Jones, DDS Chair (916) 929-6631 [email protected]

- To provide input and guidance to all partners providing dental services and coordination in Sacramento County.

2. LIBERTY Dental Plan DHCS Contracted GMC Edward Bynum - Provide currently P.O. Box 26110 Dental Plan Director, Special Projects contracted services, Santa Ana, CA 92799- Dental Managed Care (888) 703-6999 x215 administrative support. 6110 plans in Sacramento

are contracted to provide the full scope of Medi-Cal dental services. Contracted dental plans provide case management, care coordination, translation services, and customer service.

[email protected] - Participate in the medical/dental partnership, and the Virtual Dental Home VDH pilot. - Provide training for providers and community partners. - Care coordination for members. - Participate in data sharing

and data collections for outcomes.

3. Western Dental Provider of Medi-Cal Jeffrey Miller - Provide staffing (RDH, DA 530 S. Main Street dental services under Senior Vice President & & off-site dentist) for the Orange, CA 92868 LIBERTY Dental Plan. General Counsel

Western Dental/Brident (714) 571-3508 [email protected]

VDH pilot in schools and using 10 dental clinics for children who need additional treatment. - Share data with Pacific and Sacramento County Public Health for program improvement and reporting.

4. Health Net Dental Plan 101 N. Brand Blvd., 15th

Fl. Glendale, CA 91203

DHCS Contracted GMC Dental Plan Dental Managed Care plans in Sacramento are contracted to provide the full scope of Medi-Cal dental services. Contracted dental plans provide case management, care coordination,

Sean OBrien Dental Operations Director (818) 543-9021 [email protected]

- Provide currently contracted services, administrative support. - Participate in the medical/dental partnership, and the VDH pilot. - Provide training for providers and community partners. - Care coordination for members.

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translation services, and customer service.

- Participate in data sharing and data collections for outcomes.

5. Access Dental Plan DHCS Contracted GMC Alisha Hightower - Provide currently 8890 Cal Center Drive Dental Plan Director, Government contracted services, Sacramento, CA 95826 Dental Managed Care

plans in Sacramento are contracted to provide the full scope of Medi-Cal dental services. Contracted dental plans provide case management, care coordination, translation services, and customer service.

Programs (916) 679-7001 [email protected]

administrative support. - Participate in the medical/dental partnership, and the VDH pilot. - Provide training for providers and community partners. - Care coordination for members. - Participate in data sharing

and data collections for outcomes.

6. Access Dental Services Dental Van Payam Pardis - Leverage use of existing 8890 Cal Center Drive Vice President of Operations dental van at schools and Sacramento, CA 95826 (916) 563-5064

[email protected] community events to provide dental assessment and fluoride varnish to target population in the medical/dental partnership. This van has not been in use for lack of staffing and service coordination activity.

7. WellSpace Health FQHC Dental Clinics Jonathan Porteus - Contracted to serve Medi-1820 J Street Executive Director Cal/Denti-Cal patients and Sacramento, CA 95811 (916) 313-8413

[email protected] will provide VDH staffing and data sharing.

8. Sacramento Native American Health Clinic 2020 J Street Sacramento, CA 95811

FQHC Dental Clinic Britta Guerrero Executive Director (916) 341-0575 [email protected]

- Contracted to serve Medi-Cal/Denti-Cal patients and will provide VDH staffing and data sharing.

9. CARES Community Health 1500 21st Street Sacramento, CA 95811

FQHC Clinic Christy Ward CEO (916) 914-6240 cward@carescommunityhealth. org

- Leverage of existing health/dental van for children needing clinic treatment.

10. Health & Life Organization, Inc. (HALO) 7275 E. Southgate Dr., Ste. 204-208 Sacramento, CA 95823

FQHC Dental Clinic J. Miguel Suarez Clinic Director (916) 642-1872 [email protected]

- Contracted to serve Medi-Cal/Denti-Cal patients and will provide VDH staffing and data sharing. - Leverage of existing health/dental van for children needing clinic treatment.

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11.Sacramento District Dental Society 2035 Hurley Way, Ste. 200 Sacramento, CA 95825

Association of Member Dentists

Cathy Levering Executive Director (916) 446-1211 [email protected]

- Training of medical/dental providers. -Refer callers to dental plan member services and dental providers. - Provide dental education programs in schools and community events through the CSUS Dental Club and Puppet Art.

12.First 5 Sacramento Commission 2750 Gateway Oaks Dr., Ste. 330 Sacramento, CA 95833

Sacramento County Prop 10 funding agency for children ages 0 to 5 and their families

Julie Gallelo Executive Director (916) 876-5867 [email protected]

- Provide outreach and access to contractors serving families with children ages 0 to 5 and share Toothy messaging and materials. - Provide office space for Sacramento County staff implementing and managing the DTI-LDPP. - Provide meeting space for the Dental Collaboration Partners for monthly meetings.

13.Child Abuse Prevention Center (CAPC) 4700 Roseville Road, #102 North Highlands, CA 95660

Child Abuse and Neglect Prevention

Sheila Boxley President & CEO (916) 244-1905 [email protected]

- Provide oral health outreach, education and referrals to eligible children and families eligible for Medi-Cal. - Provide on-line and in-person dental training and technical assistance to service providers who work with low-income families.

14.Sacramento Covered Culturally competent Kelly Bennett - Health & Dental 8928 Volunteer Lane, health & dental CEO Navigators located in #220 insurance enrollment (916) 414-8386 community-based Sacramento, CA 95826 and navigation. [email protected] organizations, hospital

emergency departments and clinics in Sacramento County will work with families to connect with assigned dental plan and dental home. - Leverage health public information campaign funding by adding dental messaging to families.

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15.University of the Pacific, Pacific Center for Special Care Arthur A. Dugoni School of Dentistry 155 5th Street San Francisco, CA 94103

University School of Dentistry

Paul Glassman DDS, MA, MBA Professor of Dental Practice Director, Community Oral Health Director, Pacific Center for Special Care University of the Pacific Arthur A. Dugoni School of Dentistry 415-929-6490 [email protected]

- Implement and manage the VDH pilot in Sacramento and Amador Counties. - Provide system design, training, technical assistance, data, surveys and other evaluation reports.

16. Jeffery A. Saladin, DDS Childrens Choice Pediatric Dental Care 1164 National Drive, Ste. 40 Sacramento, CA 95834

Pediatric Dentist Dr. Jeffery Saladin Founder & CEO (916) 473-1783 [email protected] om

- Contracted to serve Medi-Cal/Denti-Cal patients and will provide VDH staffing and data sharing. - Leverage of existing health/dental van (Smile Keepers and CARES) for children needing clinic treatment.

17. Sacramento County DHHS Smile Keepers Program 9616 Micron Avenue, Ste. 670 Sacramento, CA 95827

Smile Keepers Tooth Truck & Dental Van

Kate Varanelli Dental Health Program Coordinator (916) 875-6259 [email protected]

- Smile Keepers Dental Van serving 8,000+ children annually. - Connect children to assigned dental plan and track if children actually saw their dentist. - Refer children who need care to Sacramento Covered for navigation of dental benefits and making appointments. -Tooth Truck leverage for VDH.

18.Sacramento County Child Health & Disability Prevention (CHDP) 9616 Micron Avenue, Ste. 950 Sacramento, CA 95827

County CHDP Cynthia Johnston Deputy Director (916) 875-6690 [email protected]

- Participate in the medical/dental collaboration with CHDP medical providers. - Participate in staff trainings.

19.Children Now 1404 Franklin Street, 7th

Floor Oakland, CA 94612

Childrens policy and advocacy

Eileen Espejo Director, Media & Health Policy (510) 763-2444 [email protected]

- Implement medical/dental collaboration. - Provide training to local agencies to build capacity to continue services after Year 2.

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- Provide technical assistance and training of any new staff in Year 2.

20. San Juan Unified School District Dave Pascoa - Refer children to dental School District Administrator partners and participate in 5309 Kenneth Street (916) 971-7375 dental education in pre-Carmichael, CA 95608 [email protected] school and kindergarten

classrooms. 21.Kaiser Permanente Hospitals 1650 Response Road Sacramento, CA 95815

High quality, affordable health care services with an integrated health delivery model

Carol Serre Community Benefit Manager (916) 614-5011 [email protected]

- Refer children in need of dental services to Sacramento Covered to connect with a dental home.

22.Dignity Hospitals 3400 Data Drive Rancho Cordova, CA 95670

Health care services Ashley Brand Coordinator, Community Benefit (916) 541-0519 Ashley.brand@dignityhealth. org

- Refer children in need of dental services to Sacramento Covered to connect with dental home.

23.Sutter Hospitals Health care services Kelly M. Brenk - Refer children in need of 2700 Gateway Oaks Drive, Coordinator, Community dental services to Ste. 2200 Benefit, Sutter Health Valley Sacramento Covered to Sacramento, CA 95833 Area

(916) 541-0519 [email protected]

connect with dental home.

24. River City Medical Group 7311 Greenhaven Drive, Unit 145 Sacramento, CA 95831

Independent Practice Association (IPA)

Effie Hubbard Ruggles Community Health Relations Manager (916) 573-3503 [email protected]

- Participate in the medical/ dental collaboration by ensuring staff attends trainings and implements skills learned.

25.Sacramento Employment & Training Agency (SETA) Head Start 925 Del Paso Boulevard Sacramento, CA 95815

Employment & Training and Head Start Administrator

Denise Lee Deputy Director Children and Family Services (916) 263-3916 [email protected]

- Participate in the VDH project in Sacramento County by connecting Head Start children to the VDH project and to a dental home.

26. DentaQuest Institute Dental Benefits Rebekah Mathews -Provide system that will 465 Medford Street Administrator & Director of Transformation help partners to conduct Boston, MA 02129 Foundation (803) 758-0558

(803) 391-9858 (c) Rebekah.Mathews@improvi ngoralhealth.com

quality improvement activities. -Support DTI-LDPP with tested tools and training.

27.Twin Rivers Unified School District

3222 Winona Way (Mailing Address) North Highlands, CA 95660

School District Bonita Mallory, MA, BSN, RN Coordinator, Student Health, Wellness & Prevention 916-566-1600, x50851 Bonita.Mallory@twinriversus d.org

-Participate in the VDH at identified school sites. -Provide coordination for dental team with the school district. - Refer children to dental partners and participate in

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5115 Dudley Blvd, Bay B-240 (Office Address McClellan, CA 95652

dental education in pre-school and kindergarten classrooms.

28. Amador County Public Health 10877 Conductor Blvd., Ste. 400 Sutter Creek, CA 95685

County Public Health Department and CHDP Provider

Connie Vaccarezza Supervising Public Health Nurse (209) 223-6407 [email protected]

- Provide program implementation and coordination in Amador County.

29. Amador County Only school district in Joanne Hassan - Coordination of consent Unified School District Amador County Health Coordinator forms and organization of 217 Rex Avenue (209) 257-5343 school staff on dental event Jackson, CA 95642 [email protected] days.

30. First 5 Amador Mailing Address: P.O. Box 815 Physical Address: 975 Broadway Jackson, CA 95642

Amador County Prop 10 funding agency for children ages 0 to 5 and their families

Nina Machado Executive Director (209) 257-1092 [email protected]

- Provide program coordination and referral of children ages 0 to 5 served through contracted programs.

31.Sutter Amador Hospital 200 Mission Blvd. Jackson, CA 95642

Provider of health care services

Anne Platt CEO 209-223-7500 [email protected]

- Refer children in need of dental services to connect with a dental home.

32.Nexus Youth & Family Services 621 New York Ranch Road Jackson, CA 95642

Family Resource Center Tara Parker Director of Grants Administration (209) 257-1980 [email protected]


33.California Tribal TANF Partnership Amador County 801 Court Street, Ste. 106 Jackson, CA 95642

Tribal Resource Center Joni Drake Site Manager (209) 257-6150 [email protected]


34.Oral Health Solutions, Inc. 101 Broadway, #248 Oakland, CA 94607-3745

Dental IT Systems Bruce Boyer President (510) 629-4929x801 [email protected]

Design and host dental data collection system for iPhones, iPads, laptops and desktops. Generate monthly and annual reports.

1.3 Letters of Participation/Support

Required Letters of Participation Agreements and/or support for all participating entities attached.

Sacramento County is the Lead Agency in this application where two Counties Sacramento and Amador are working together to bring the services outlined in the proposed pilots to the children of both counties. This application contains multiple community partners as Participating Entities,

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mailto:[email protected]

including the Sacramento Native American Health Center, the California Tribal TANF Partnership, Family Resource Centers, and Federally Qualified Health Centers and many other key partners.

1.4 Collaboration Plan

Sacramento County is unique in that it is one of only two California counties with Geographic Managed Care (GMC), and the only one where it is mandated, as a result, the majority of the Medi-Cal beneficiaries in Sacramento are in a GMC plan. Sacramento County is also unique because AB 1467 was signed on July 1, 2012 to create the Medi-Cal Dental Advisory Committee (MCDAC). MCDAC provides oversight and guidance to improve Denti-Cal utilization rates and the delivery of dental care services, including prevention and education services. MCDAC members include: the three dental plans contracted with DHCS, Sacramento County Public Health Department and Smile Keepers Program, representatives from the First 5 Sacramento Commission, local non-profit organizations, the local dental society, and other interested individuals including parents. Many members of this team have been meeting monthly since 2008 as the Childrens Dental Task Force to improve dental access for children. Members of this group will participate in the DTI-LDPP, which is named Every Smile Counts! with the tag line Connecting Kids to Dental Care.

In Amador County, the Amador County Oral Health Task Force (OHTF) was established in 2004. Members have included the public health nursing director, a local dental office coordinator, school nurses, volunteer dental hygienist, senior services representative, Head Start health coordinator, Amador Community Foundation executive director and First 5 Amadors executive director. Over the past year a dentist and a services coordinator from Delta Dental have become regular attendees to the Task Force meetings.

All partners and subcontractors represented in this application will meet on a monthly basis to share DHCS DTI pilot requirements and lessons learned, troubleshoot program challenges, improve program quality and share data for reporting purposes. This collaborative will be known as the Dental Collaboration Partners (DCP) and will meet in Sacramento and Amador counties. Sacramento County as the Lead Entity will attend meetings and meet with the partners on an individual basis as well as in the collaborative meeting. This meeting will be separate from the established Medi-Cal Dental Advisory Committee and Oral Health Task Force meetings but will coordinate with those committees as well. The coordination meetings will follow Roberts Rules of Order, and issues that arise will be included in an agenda for discussion at the meeting and decisions will be made by consensus. If there is an issue identified with coordination between partners, a one-page Dental Alert Form will be used to communicate the issue to Sacramento County staff who will then work with the parties to resolve the issue. These alerts will also be addressed at the monthly DCP meeting to ensure appropriate steps were taken. The DCP will work to create a plan for sustaining efforts, document successful interventions and coordinate any additional resources brought to the pilot. Sacramento County staff will be the main point of contact for this collaboration plan and will be responsible for communicating with all partners including DHCS and CMS.

Since the Sacramento MCDAC and Amador OHTF are established collaboratives, the members have been working to break down silos, as representatives of Dental Plans, dental providers, beneficiaries and other stakeholders have worked to address barriers to dental care for children in the Medi-Cal system. Their success in increasing the utilization rates from 20% in 2008 to 39.6% in 2014 in Sacramento County is a testament to the ability to work together to find common solutions and resolve issues. The Amador OHTF has worked to fundraise and has implemented

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dental assessments and fluoride varnish on a limited basis. The OHTF has also developed a relationship with a dental provider that will provide some no-cost dental services when connection with a Fee-for-Service dentist is not possible in Amador County.

As outlined in Section 1.4, Collaboration Plan, the Sacramento County Collaboration is known as Every Smile Counts! Connecting Kids to Dental Care Dental Collaboration Partners. The collaboration met formally on Thursday, January 12 and will continue to meet monthly for the duration of the pilot. Participating entities will share data, milestones, and integration methods and communicate LDPP requirements and reporting. Integration will occur as part of this process and all family-serving organization will include dental education and referral as a program norm. In addition, a Dental Alert System will be created to report any issues with referrals and dental services between partners. Completed Dental Alert Forms will be responded to within 72 hours by Sacramento County staff. This information and resolution will be shared at the monthly meeting as a learning opportunity for all partners.

Silos will be minimized by having monthly meetings with the members of the collaborative to assess progress and work through any presenting problems. In addition, members of each pilot project will also meet to discuss and share data and share successes and barriers. An email list serve will be set up to ensure that members get regular updates on activities, and will be encouraged to work together on joint outreach activities.

Sacramento County will convene the monthly Every Smile Counts! In-person meetings and maintain an email distribution list to share pilot requirements (Sec. 1.4).

Sacramento County DHHS will fold in dental lessons learned and trainings into all available trainings currently provided by the county. Two examples of trainings to include are How to Make a Dental Appointment for Medi-Cal Families and Educating Families about Oral Health.

Sacramento County will reinstitute MAA billing to sustain infrastructure and interventions developed as part of the pilot projects. CMAA billings were discontinued in 2010 as part of budget cuts during the economic downturn in Sacramento County.

Debra Payne is the main point of contact for this pilot as identified in Section 1.1.

Monthly Every Smile Counts! Meetings are convened by the lead entity and are mandatory for participating entities. A standing agenda item will be DHCS Communications & Reporting, Reviewing Data Reports, Dental Alert Case Resolutions and Continuous Quality Improvement. Members are strongly encouraged to attend in person, however, a call-in option will be available for those from out of town.

Sacramento County as the lead agency will coordinate monthly meeting. The Coordinator will also run separate meetings for each of the pilot projects. These will be conducted on a monthly basis. The meetings will be open meetings. Decisions will be made by consensus to get buy-in from the participating agencies.

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Section 2: General Information and Target Population

2.1 Target Population Sacramento County Sacramento County has a total population of approximately 1.4 million people. Children aged newborn to twenty years comprise 417,432 of that number1. Approximately 34.5 percent of those children have Medi-Cal as their primary health and dental insurance. Of the 144,315 children, most are enrolled in Geographic Managed Care (GMC - 140,634) and a small number of children have Fee-for-Service (FFS - 3,681)2. Sacramento County proposes to serve Medi-Cal eligible children age 0 to 20 and increase utilization rates by at least 5 percent annually.

In 2009 it was determined that specific data for children utilizing Medi-Cal managed care dental benefits in Sacramento County was not available. First 5 Sacramento funded a report entitled Sacramento Children Deserve Better by Barbara Aved Associates in 2010. This report found that only 20 percent of all eligible children were utilizing benefits according to 2008 data. In 2015, a follow-up study was completed; local dentists and the three dental plans funded the updated study. It found that while utilization had improved to 39.6 percent of eligible children utilizing benefits, many improvements still needed to be made. This updated report was published in December 2015 and is being used for the Sacramento County assessment requirement for the Local Dental Pilot Program application. According to Sacramento Children and Dental Care: Better Served than 5 Years Ago?, published by Barbara Aved Associates, dental disease has remained at high rates for children in Sacramento County. The following data has been taken from that report.

While there are limited data available to measure the extent of dental disease among children in Sacramento County, pre-kindergarten assessments3 provide a picture of disease prevalence. Based on the most recent three-year average (2012-2014), screening results for the reporting school districts in Sacramento County (nearly all) show that one-quarter (24.3%) of the children had evidence of untreated dental decay (Figure 1).

1 Census Bureau American Community Survey 2014. 2 Sacramento Children and Dental Care: Better Served than 5 Years Ago? Barbara Aved Associates Dec 2015 3 AB 1433 (enacted in 2006 through the efforts of the California Dental Association) required that children have a dental checkup by May 31 of their first year in public school, at kindergarten or first grade. The requirement for screening was later changed to a voluntary basis because of school funding issues and the removal of certain mandates. The CDA is working to restore the oral health screening requirement.

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Figure 1. Results of Pre-Kindergarten Dental Screenings, Reporting Schools in Sacramento County

Source: California Dental Association AB 1433 Pre-K Reported Data

Data from Sacramento District Dental Societys Smiles for Kids Day 2014 screenings of 25,500 children in grades K-64 are also helpful in estimating the prevalence of oral disease among Sacramento children. Smiles for Kids Day has been sponsored by the Sacramento District Dental Society annually since 1991 and has screened and served over 400,000 children. More than $13.5 million has been donated and local dentists have provided over 16,000 children with free dental care. These screenings in 2014 revealed that 70% needed no care, 23% needed some care (some evidence of disease), and 7% required urgent care (Figure 2).

Figure 2. Results of Preschool-Sixth Grade Dental Screenings,

Sacramento County, Selected Years

Source: Data for the first three periods are from Sacramento County Smile Keepers Program and are preschool-6th grade. Data from the last period are kindergarten-6th grade, and are from the Sacramento District Dental Society.

4 The screenings were performed by dentists in 102 lower-income area schools offering Title I free lunch programs.

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The data from Smile Keepers, a school-based program of the County of Sacramento, which has served children since 1980, indicated that among the 8,041 higher-risk and predominantly preschool children screened by that program in 2013-14, between one-quarter and one-third (29%) showed some evidence of decay and needing treatment and 5% needing immediate treatment (e.g., severe dental caries).

The results of the assessments provide an estimate of the unmet need in Sacramento County; about one quarter of children up to age 12 years have untreated dental disease, and the utilization rate for all children age 0 to 20 is only 39.6 percent. At that utilization rate, more than 80,000 children have not utilized their dental benefits. The target is to raise the utilization rate by at least five (5) percent per year, each year of the pilot.

Amador County The 2016 estimated total population of Amador County is approximately 38,000 people according to SuburbanStats.org. The data report from Social Services (7-15-16) reports there are 2,684 children ages 0 to 20. Amador County births are approximately 275 - 300 per year; in tracking school enrollment numbers, each grade tends to be approximately 300 children. The target population will be at least two-thirds of the 2,390 children with a special focus on younger children in order to accomplish the greatest impact over time.

As a rural County, Amador is considered a medically underserved area, with residents experiencing difficulty accessing medical and dental services. According to the Sutter Amador Health Survey Assessment (HSA) Communities of Concern 2016 Report, six zip codes had emergency department rates (113.25) due to dental health issues that exceeded the state benchmark of 41.80. The rate in zip code 95642 (Jackson) was more than five times higher (208.68) than the state rate. Participants in this report indicated that there was a lack of dental providers in the Amador County area and some participants ranked dental health issues and access to dental care as a top priority for the HSA. The findings indicated that there are few dentists practicing in Amador County area and none of those dentists accept Denti-Cal insurance. In addition, key informants expressed a concern that a lack of access to dental care often results in episodic care with resultant dental crises.

The focus is early intervention and prevention and younger children will be targeted, but the three proposed pilots outlined in this proposal would serve any child requiring dental care and referral. The target population for the DTI pilots will be children ages 0 to 20 in Sacramento and Amador Counties with Medi-Cal managed care and fee-for-service dental benefits.

The Every Smile Counts! Collaborative plans to use the network of social service, dental and medical providers that are currently providing non-dental services to the target population to implement the pilot projects. In the first pilot project, the Denti-Cal providers will expand services to a non-traditional setting in schools to increase availability and reduce barriers to care. In the second pilot project, pediatricians serving the Medi-Cal population will provide the dental preventive services to their practices and provide a warm hand-off referral to dentists. In the third pilot, a dental component will be added to the many family service organizations already serving low-income populations.

The selected strategies aim to reduce barriers to care for the target population by using non

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http:SuburbanStats.org

traditional settings for care (schools) and using Primary Care settings to provide dental services. Two barriers that were identified in the needs assessment were lack of transportation to get children to appointments and difficult scheduling appointments at convenient times. Providing services at school will eliminate the difficulty of having to pull children from school for dental appointments and will eliminate the need for transportation. Providing services in non-traditional settings will also increase availability of appointments.

Participating entities have the in-person presence in the communities to reach the hard-to-reach populations who are not currently utilizing benefits. Most of these families have backgrounds with Adverse Childhood Experience (ACE) and cannot be reached by a mail or phone outreach campaign. Having navigators and outreach workers with knowledge of these communities work with the families to provide education and assistance in accessing services will also help to reduce barriers to care and increase utilization rates.

The contracted Denti-Cal dental plans are among the participating entities and will work with partners on beneficiary identification and outreach as is described in Section 3.1.1, page 14. In addition, Sacramento Covered has the ability to check the MEDS system to see if the children are enrolled in Medi-Cal and if not, then get them enrolled. They also can share with enrolled and assigned families which dental plan they are assigned to and get them connected to their dental services.

All VDH providers will be enrolled in Dental Managed Care and Medi-Cal/Denti-Cal Fee-For-Service so that dental services provided via VDH to Medi-Cal beneficiaries may be claimed appropriately, e.g., Access Dental, Liberty Dental or Health Net will be billed for beneficiaries enrolled in Dental Managed Care delivery system or the Medi-Cal/Denti-Cal fiscal intermediaries for beneficiaries enrolled in the Fee-For-Service delivery system.

The Sacramento County application will utilize strategies and measures outlined in STCs 106-108 specifically Domains 1 and 3. The goal for utilization rate increase is at least 5 percent per year for the term of the pilot. The full description is laid out in Section 3, beginning on page 13 of the application.

Sacramento County will work with participating entities to establish at least one Denti-Cal dentist in Amador County as soon as possible. At least one Sacramento County FQHC has selected a site in Amador County to establish a new clinic. In the meantime, children can access needed dental treatment through Fee-for-Service at one of the five (soon to be six) FQHCs serving children in Sacramento County. The VDH will also be an innovative service delivery system that has not been offered prior to this pilot in Amador County.

Section 3: Services, Interventions, Care Coordination and Data Sharing

3.1 Services and Care Coordination

The Sacramento County pilot will be known as Every Smile Counts with the tag line Connecting Kids to Dental Care.

The proposal from Sacramento County will address two domains: Domain 1: Preventative Services Domain 3: Continuity of Care

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The pilots proposed by this application are: 1. VDHs with care coordination in schools in Sacramento and Amador Counties, 2. Medical/Dental Partnership with care coordination in both counties, and 3. Training and education for community service providers in both counties to add a dental

component to service provision when serving families with children.

The goals of these pilot projects are aligned with the goals of Domains 1 and 3.

The Sacramento County DTI will test the following three innovative strategies:

1. Delivery of full dental preventive services in a non-traditional setting combined with

teledentistry. In this strategy, a clinic team will provide dental exams, x-rays and fluoride

varnish for children at school sites. Medical information and x-rays will be transmitted to a

dentist in a dental office for review and consultation.

The project goals are:

i) increase in children with an established dental home and, ii) increase percentage of children who receive preventive dental services; iii) increase in early diagnosis and treatment of caries in children.

The anticipated outcome will be improved oral health for children in participating schools.

The performance metrics will be:

i) number of children in participating schools who have not seen a dentist in the previous year;

ii) number of children in participating schools who have seen a dentist in the previous year;

iii) number of children seen by the dental teams at the schools; iv) number of children diagnosed and treated for dental caries.

The performance metrics will be measured twice a year.

2. Provide dental assessment and fluoride varnish at pediatricians offices, combined with warm hand-off to dentists. The Project goals are:

i) increase in children with an established dental home ii) increase percentage of children who receive preventive dental services iii) increased number of referrals to dentists that result in a dental visit.

The anticipated outcome is increased confidence of pediatricians to conduct dental assessments, and establishment referral system from pediatricians to dentists. The performance metrics are:

i) number of children that receive dental assessment and fluoride varnish in participating pediatricians offices

ii) number of successful referrals from participating pediatricians office to dental offices

iii) number of children in participating pediatricians practices with a visit to the dentist in the previous year

iv) number of children in participating pediatricians practices who have not seen a dentist in the previous year.

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3. Use trauma-informed care to provide navigation/care coordination to families seeking care in emergency rooms for dental problems. The innovation is based on work done in medical care where it was found that people who are frequent users the Emergency Rooms often have psychosocial problems that may be a result of childhood trauma. By having Health Navigators stationed in Emergency Rooms to provide care coordination, education and assistance with accessing services, the patients are able to take better care of themselves and receive appropriate treatment.

The goals of this strategy is to:

i) increase number of children with established dental homes ii) increase early diagnosis and treatment of dental caries and prevent

complications. The desired outcome is that there will be reduced use of the Emergency Rooms for dental problems. The performance metrics will be:

i) number of children that receive care coordination for dental care resulting in a dental visit

ii) number of referrals made to other social services.

3.1.1 VDH in Sacramento and Amador Counties - Pilot #1

The VDH was developed and tested by the Pacific Center for Special Care at the University of the Pacific School of Dentistry, which is an innovative and customizable oral health delivery system. The VDH delivers oral health services in locations where people live, work, play, go to school and receive social services. It utilizes the latest technology to link practitioners in the community with dentists at remote office sites.

Using the VDH system, Registered Dental Hygienists in Alternative Practice (RDHAP), Registered Dental Hygienists (RDH) working in public health programs and Registered Dental Assistants in Extended Functions (RDAEF) can keep people healthy in community settings by collecting diagnostic records, providing preventive procedures and interim therapeutic restorations education, and case management. Where more complex dental treatment is needed, the VDH connects patients with dentists and dental clinics in the area. In Amador County, it is expected that WellSpace Health will open a new FQHC clinic in early 2017. In the meantime, more extensive services can be provided in a partner dental van or be transported to the Rancho Cordova WellSpace Clinic.

This pilot will demonstrate the ability of the VDH system to enhance care delivery and oral health of children in two distinct communities:

Rural Fee for Service (FFS) communities in Amador County Urban school district in Sacramento County within the GMC system

The following Partners will participate in the VDH pilot: 1. Dental Care providers WellSpace Health, Sacramento Native American Health

Center, HALO Clinics, Western Dental Clinics, Childrens Choice Dental, and Access Dental.

2. Participating host sites at selected schools in Sacramento and Amador County 3. GMC Dental Plans Access Dental, Liberty Dental and Health Net

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4. University of the Pacific Special Services

Roles and Responsibilities of Partners in Sacramento and Amador County The following is a list of roles and responsibilities that will ensure success of the demonstration.

1. The dental care providers (WellSpace Health, Sacramento Native American, HALO Clinics, Western Dental, Childrens Choice Dental, and Access Dental) will be responsible for the following:

Hire and pay the salary of the on-site dental teams. The dental team will consist of dental hygienists and dental assistant/navigators on-site at schools, in communication with off-site dentist tele-health who will work in the community sites or work with on-site teams hired by another entity. The dental providers will bill Medi-Cal for services rendered.

Create a care coordination system for the project and supply care coordination resources to help track patients, make appointments and get patients who need dental appointments into those appointments.

Designate an off-site dentist to review tele-health dental records and direct care of the on-site dental team.

Accept referrals and provide treatment that cannot be provided in the community site for patients who are deemed to have advanced disease that warrants a visit to a dental office.

2. Participating schools/host sites will: Provide space and host the on-site dental teams Help schools develop and process agreements Help with arrangements for scheduling and integration of the system into school activities

and processes Facilitate children being seen and coordinate activities whose parents agree to participate

In Amador County, the project will involve four elementary schools and six preschools all with 60% or more children qualifying for free/reduced lunches. Three of the preschools are co-located with the elementary schools and two are within one mile of the nearest elementary school.

The sites in Amador County are: Jackson Elementary and State Preschool / Jackson Head Start Ione Elementary and State Preschool / Ione Head Start Pioneer Elementary and State Preschool Plymouth Elementary and State Preschool

Total number of children in the following grades is 1,273 (4 elementary schools and 4 state preschools) of which approximately 60 percent are Medi-Cal eligible: State preschool 96 Kindergarten 241 1st grade - 295 2nd grade - 254 3rd grade 309 Jackson and Ione Head Start / Early Head Start = 78 (120 if home-base families are

included)

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In Sacramento County, the host sites for this demonstration will be pre-school and elementary schools in the Twin Rivers School District (The District), including 14 pre-schools and elementary schools, which are feeder schools to Grant High School. The role of the District will be to introduce the demonstration pilot to the administration of individual schools and support its adoption and integration.

The elementary schools in the Twin Rivers District are: Babcock Elementary K-6 enrollment: 338 Castori Elementary K-6 enrollment: 690 Del Paso Elementary K-6 enrollment: 543 Fairbanks Elementary K-6 enrollment: 361 Garden Valley Elementary K-6 enrollment: 389 Hagginwood Elementary K-6 enrollment: 409 Harmon Johnson gr 3-6 enrollment: 646 Noralto Pre-2 enrollment: 500 Northwood Elementary K-6 enrollment: 476 Smythe Charter K-6 enrollment: 629 Strauch Elementary K-5 enrollment: 635 Morey Avenue ECDC enrollment 451 Woodlake Elementary enrollment 435 Oakdale Elementary/Head Start enrollment 531

The total number of children served will be 3,000 in the first year. See Attachment 1 (Maps) for additional VDH school locations and provider information.

3. GMC Dental Plans This demonstration pilot will be unique in being integrated into the GMC system in Sacramento. The following is a list of roles and responsibilities that will ensure success of the demonstration.

All three dental plans (Access Dental, Liberty Dental and Health Net) participating in the GMC system will participate in and support this demonstration. Dental Managed Care (DMC) plans in Sacramento are contracted to provide the full-scope of Medi-Cal dental services. In addition the DMC plans provide for additional services related to case management, care coordination language assistance, and customer service.

The Plans will have the following responsibilities: Enlist and support participation of the provider dental offices in the geographic area of the

demonstration. Help create and work with care coordination system (community-based partners such as

Sacramento Covered and Birth & Beyond Family Resource Centers) for the project; supply care coordination resources to help track patients and make appointments/get patients to their appointments.

Collect and supply data regarding the utilization of dental services, procedures performed, and financial aspects of the demonstration pilot as allowed by business associate agreements with DHCS.

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Support the LDPP in Sacramento County by providing currently contracted services, such as administrative support, as well as assistance to provide plan members the additional contracted services.

Work with VDH team to develop care plan for children who need additional dental services and refer to assigned Plan dentist.

Provide assistance to beneficiaries to schedule and get to appointments when needed. This could include transportation and language assistance.

GMC Plans shall work with the LDPP partners and internal customer service teams to ensure there are processes in place to assist members on-site through the toll free numbers quickly and efficiently. Internal customer service teams shall be made aware of this program, and LDPP partners will be trained on best practices to assist members. If there is a need to develop an alternate member assistance process, the LDPP and the DMC plans shall work through a proposed process.

4. University of the Pacific (UOP) The Pacific Center for Special Care at the University of the Pacific School of Dentistry has developed and tested an innovative and customizable oral health delivery system called the VDH system of care. Incorporating the VDH system in a DTI LDDP in Sacramento offers the opportunity to demonstrate that managed care dental plans can participate and use this system to reach the vast majority of the population with a system that emphasizes prevention and early intervention, improves the oral health of the population, and lowers the significant personal, societal, and financial costs that result from neglected dental disease.

In both Amador and Sacramento Counties: UOP will design and direct the integration of the VDH system. UOP will be responsible for: Attend and work with the Collaborative Dental Partners (CDP), a broad stakeholder advisory

group System design resulting after meeting with all of the participating groups Specific protocol development for each site Training of personnel in the health plans, participating provider dental office/clinics and

community sites Technical assistance over the life of the demonstration Collection of qualitative and quantitative data Data aggregation and analysis Preparation of reports and recommendations

3.1.2 Medical/Dental Partnerships with Care Coordination Pilot #2

Young children are more likely to access medical care than dental care. Medical providers therefore have an opportunity to play an important role in assisting young children and their families to access dental care. In the Medical/Dental Partnership, providers will be trained to conduct a dental assessment as well as identify members in their practice who do not have a dental home and refer them to a dentist as part of this collaboration.

Partners participating in the medical/dental partnerships are: 1. Children Now 2. Sutter Amador Hospital & Amador OHTF

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3. Medi-Cal Health Plans River City Medical Group (future planning for Molina and Kaiser)

4. Dental GMC providers 5. GMC Dental Plans Access, Liberty Dental and Health Net

1. Children Now will provide project support for implementation of the Medical/Dental collaboration using the following strategies:

Building Medical/Dental Partnerships: Children Now will work with pediatricians and other medical and health care providers

serving children to offer preventive dental services such as oral health assessments and fluoride varnish; and

Children Now will work to co-locate dental and pediatric services whenever possible to facilitate referral of children to dentists.

Growing Community Partnerships: Children Now will train and utilize an oral health team in the medical office to provide caries

risk assessment; dental screening, fluoride varnish and referral back to the patient's assigned dental plan/dental home. Outreach efforts will be expanded through schools, Family Resource Centers, Head Start, Women Infant and Children (WIC), Child Health and Disability Prevention Program and other community-based programs.

Scope of Work The following scope of work is divided into two phases and intended to encompass a 22-month period. Children Now will support the Sacramento LDPP regarding the following strategies and activities:

PHASE I Start-Up and Training Design and implement a training program for providing an oral health assessment, fluoride

varnish and Medi-Cal billing to deliver to participating medical sites and oral health teams. Develop training materials with consistent messaging for medical sites oral health teams to

use in implementing project. Deliver 5 training programs in English and Spanish, disseminating materials in English and

Spanish to participating sites at each program. Determine needs and provide technical assistance and guidance to sites participating in the

project via regular (anticipating that these may be approximately bi-weekly) in-person meetings and/or phone calls.

Following all 5 trainings, establish a learning collaborative for participating organizations that are being trained and develop a Train-the-Trainer module that organizations could replicate.

Recruitment Identify and recruit medical sites (at least 5 sites) and/or community based organizations

that navigate children/families into dental care to participate in the pilot. Arrange in-person meetings with potential medical sites and/or community-based

organizations to pitch pilot project and assess interest in participating in the pilot. Confirm with the Sacramento County project team which sites to onboard into pilot.

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Project Management Participate in regular project meetings with County of Sacramento Dental Collaboration

Partners and other pilot project leadership in-person and via phone, as scheduled and requested;

Contribute to progress and year-end reporting processes.

PHASE II Training and Technical Assistance Ensure implementation of the train-the-trainer modules and track number of sites/people

trained. Host and facilitate 2-3 learning collaborative events for participating medical sites,

community-based organizations and dental providers. Develop agendas and materials for learning collaborative events with project partners. Continue to provide technical assistance in-person and via phone to participating sites, as

needed.

Project Management Participate in regular project meetings in-person and via phone, as scheduled and

requested. Contribute to progress and year-end reports.

At the end of the 22-month partnership, local agencies in Sacramento County (such as Sacramento Covered) staff will carry on providing the above activities.

2. In Amador County a medical/dental partnership between Sutter Amador Hospital and the OHTF has happened on a limited basis in the past but the DTI-LDPP would enable the partners to expand services to more children.

3. Medi-Cal Health Plans will participate to recruiting medical providers and with organizing the training. They will also help medical providers to identify children in their practice who have not been seen by a dentist in the last year.

4. GMC Dental Providers will support beneficiaries in finding the assigned dentist and help facilitate the beneficiaries being seen and provide other services as follows: Enlist and support participation of the provider dental offices in the geographic area of the

demonstration. Help create and work with care coordination system (community-based partners such as

Sacramento Covered and Birth & Beyond Family Resource Centers) for the project; supply care coordination resources to help track patients and make appointments/get patients to their appointments.

Collect and supply data about the utilization of dental services, procedures performed, and financial aspects of the demonstration as allowed by business associate agreements with DHCS.

Support the LDPP in Sacramento County by providing currently contracted services such as administrative support as well as assistance to provide plan members the additional contracted services.

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Work with oral health team to develop care plan for children who need additional dental services and refer to assigned Plan dentist.

Provide assistance to beneficiaries to schedule and get to appointments when needed. This could include transportation and language assistance.

GMC Plans shall work with the LDPP partners and internal customer service teams to ensure there are processes in place to assist members on-site through the toll free numbers quickly and efficiently. Internal customer service teams shall be made aware of this program, and LDPP partners will be trained on best practices to assist members. If there is a need to develop an alternate member assistance process, the LDPP and the DMC plans shall work through a proposed process.

5. GMC Dental Plans Access Dental, Liberty Dental and Health Net Member services will assist with coordination with the Health Plans to identify children who

have not seen a dentist in the past year.

3.1.3 Community Care Coordination and Training Pilot #3

The Community Care Coordination and training will involve using Community Health Workers (CHW) and navigators to provide a consistent oral health message to the families and assist them in accessing dental care services by working with the dental plan member services to establish a dental home for children.

The participating entities in Pilot #3 are: 1. Child Abuse Prevention Center including the Birth and Beyond Program (On-Line & In-

Person Training & Referral of Children) On-Line Training will be available to Amador County as well

2. Sacramento Covered (Providing Health & Dental Navigators in Hospitals & Insurance Enrollment & Case Coordination for Parents)

3. Sacramento District Dental Society (Training of Medical/Dental Professionals and Dental Education in Schools through Puppet Art and CSUS Dental Club) Also available to Amador County

The roles of the participating partners is as follows:

1. Outreach and Referral: The Birth & Beyond Family Resource Centers that operate under the Child Abuse Prevention Center, serve over 5,000 children and families annually, the majority of whom are Medi-Cal eligible. There are one-on-one services through home visitation and center-based services, which include a wide range of social, emotional, economic, crisis, educational, and safety services. This model uses Community Health Workers (CHWs) to provide coordination of services. Through this pilot project, the CHWs will also provide coordination assistance in the following ways: Add a dental component to working with individual home visits with families, Distribute dental information at the nine family resource centers, Provide dental education as a part of parent education classes held at the family resource

centers and throughout the communities, Provide dental information through school liaisons in their work with the schools, and

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Include dental information to the health, community and school fairs and outreach events.

2. Training: Dental related training will be a key component for family support personnel. A range of dental training approaches will expand the capacity of the grant and facilitate the potential for access to other funded agencies in the program. The Child Abuse Prevention Center will provide the training using an on-line system that will enable multiple trainings at multiple sites to take place. CAPC will develop a training curriculum and use the Learning Management System (LMS), which has the capacity to do on-line registration, tracking of trainees and their organization, prompting for fresh-up training, evaluation of training, delivery of on-line courses, and other potential time and cost saving approaches. The training will be accessible on a continuous basis to partners and/or expanded to reach additional agency staff to further the access to children and their families. It will be also be combined with in-person training, access to questions and answers, and/or other types of technical assistance.

3. Care Coordination: Patient Navigators (PN) provides onsite assistance to emergency room patients that are disconnected from health and dental care. Using motivational interviewing, the health navigators can learn why a family has not connected with their assigned dental home, provide education and connection to their dental home with a warm hand-off by making an appointment and following up to ensure that the appointment is kept. PNs connect with patients during their visit; provide education and support to establish medical and dental homes in primary care settings in the community. Nearly all patients served by the PNs are uninsured or covered by Medi-Cal. There are Patient Navigators stationed at all the major hospitals: 5 PNs at the Dignity Health Hospitals; 4 PNs at UC Davis hospitals; and 3 at Sutter Health Hospitals. There are an additional 14 Patient Navigators at various centers in the community. In 2015, the patient Navigators provided 7,044 navigation services (connection to health, dental and other resources), 13,119 enrollment services (connection to medical and dental coverage) and 20,163 total health resources (all ages). In addition, a partnership with the three dental plans (Health Net, LIBERTY and Access) is being developed to provide a dental portal so that health and patient navigators can efficiently access dental plan assignment and provider assignment to families so that they may make dental appointments.

All Health Navigators, regardless of position or funding stream are equipped to provide: Health and dental literacy education (how does coverage work/how to access) Health and dental coverage assistance and follow up (how to enroll) Connection to local health and dental care resources (and assistance to schedule

appointments) Assistance to overcome barriers to care (transportation, interpreting) Connection to other community resources (WIC, CalFresh, housing, emergency food,

utility bill assistance, legal aid) Follow up services to ensure care is established and services are received In-person, culturally competent and unbiased assistance

4. Additional Outreach and Education - Sacramento District Dental Society (SDDS):

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Sacramento County DTI - LDPP will leverage the public information educational campaign funded by Sutter for medical homes to include a dental message. The Sacramento District Dental Society (SDDS) will also provide support for training of medical and dental staff; provide assistance to families in navigating the system to access dental services.

Purpose of involvement: To be the conduit to the partners in the following ways:

1. Education and outreach for kids to teach their parents about oral health and the need to go to the dentist and about the dental home through the CSUS Dental Club and Puppet Art

2. Train the providers training and recruitment to dentists and medical providers for access options, provider options

3. Outreach Day do work in conjunction with Smiles for Kids Day 4. SDDS to be the referral phone number to connect parents who need care, connection to

their plan (SDDS is the community conduit) for access to dentists 5. Advertising campaign partner with other entities and partners of the grant and leverage

on-air talent

The three pilot projects will have representatives attend the monthly coordinating meeting to share information and coordinate services. In addition, the GMC Dental plans will play a key role in coordinating services for beneficiaries and preventing duplication of services. This will also require a system to share data in a database.

Other Coordinating Efforts in the County The Dental Society and partners of the DTI collaboration will distribute information to Denti-Cal providers about the Domain 2 pilot and encourage them to opt in. Children identified for additional workup through the DTI VDH pilot will be referred to dentists that are participating in the domain 2 pilot.

The VDH partners will coordinate with the Center for Oral Healths Early Smiles Sacramento Program to ensure that targeted schools are not duplicated with DTI LDPP funds. The Center for Oral Health and its partners (Liberty Dental, Access Dental, Health Net, and Sacramento Covered) network with agencies throughout Sacramento County that serve children and their families. Through these networks and with technical assistance and training from the Center for Oral Health, these agencies will provide the three pillars of the Early Smiles Program oral health education, dental screenings and navigation to a dental home (ESN) for 1st and 3rd grade children. Early Smiles Sacramento has MOUs in place with Robla and San Juan Unified School Districts. Early Smiles Sacramento is considered a partner and has agreed to meet monthly as a member of the DCP.

The Sacramento County Public Health Departments Smile Keepers dental van program, which provides preventive services to children attending low-income schools, in addition to other available vans such as Access Dental Center will provide restoration services in Amador County and preventive services at several WIC sites in the County. The staff working at these sites has access to the Sacramento County database system to help families determine their dental plans and access dental care. In anticipation of expanding collaboration with the dental plans, the Smile Keepers staff will request additional information (DOB and Medi-Cal number) on the preschool consent forms to better assist families and school staff in accessing care. The dental van will

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operate in Amador County in place of a Medi-Cal Clinic for children that require restorative services beyond the scope of the VDH sites.

A Sacramento County Chart has been created that shows what services exist now and what will be provided under DTI-LDPP funding (Attachment 2).

The outreach, patient navigation and care coordination activities included as pilot #3 are not duplicative of existing CMAA activities. The proposed activities will be enhanced with specific education messages geared toward dental health. In addition, navigators/outreach workers will be trained in how to provide trauma-informed care and conduct patient-centered motivational interviewing techniques to enhance results. Currently, Sacramento County Public Health is not claiming these codes, but will look to implement this process for sustainability of the project.

The project will, as much as possible, use existing materials, with additional material developed based on the needs.

3.2 Innovations, Interventions, and Strategies

VDH Pilot Project # 1 The VDH activity will use the methodology developed by the University of the Pacific school of dentistry in its six-year proof-of-concept demonstration and apply it to two designated target populations, one in Sacramento County and one in Amador County. This pilot will demonstrate that the VDH system can function in both the GMC environment and in a fee-for-service county. In addition, this specific pilot will be structured to demonstrate the ability to improve the health of the target population and lower the cost of treating consequences of untreated dental disease. Sacramento County will pay incentives to the dental providers that participate in required training for the VDH pilot in Years 1, 2, 3, and 4.

Incorporating the VDH system in a DTI LDDP in Sacramento offers the opportunity to demonstrate that managed care dental plans can participate and use this system to reach a larger portion of the population with a system that emphasizes prevention and early intervention, improves the oral health of the population, and lowers the significant personal, societal, and financial costs that result from neglected dental disease. The innovation of the VDH model is that: It brings dental care out of the traditional clinic setting to the patients environment in this

case, the school, thus making it more patient-centered. Dentists work with a geographically distributed team of allied professionals and use tele

health technology to communicate with the team, evaluate the patient and make treatment decisions.

The use of telehealth in a non-traditional health setting (school).

The benefits of this pilot will be to demonstrate that incorporating a VDH system focused on children can allow the system to:

Reach many more Denti-Cal beneficiaries than are currently being reached in the geographic areas where this demonstration will take place

Integrate oral health activities into the environment, activities, and processes of community sites where children already are

Apply proven prevention and early intervention procedures in community locations

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such as schools and pre-school programs Establish a continuous presence system where the on-site dental team is present in

the community site throughout the school year. This is known to increase awareness and focus on oral health, which is critical to support adoption of health-producing daily mouth care and tooth healthy diets

Keep the majority of children healthy on-site in the schools and pre-school sites, and importantly, verify through the tele-health system that they are healthy. This is possible because the dentist is involved through the tele-health system and can determine which children are healthy or can be made healthy through services provided by the dental hygienists on-site

Refer and pay incentives for those children with advanced disease to dental offices/ clinics for treatment of those problems, while maintaining on-going diagnostic and prevention services in the community

Improve the oral health of the children served in this demonstration as measured by incidence of untreated dental caries, signs of pain and infection, and use of the hospital emergency department and operating room services for dental care

Note: There will be far fewer in-office visits than traditionally needed since the majority of care will take place in the community (2/3 in schools vs. 1/3 in office/clinic).

Goal: The goal of the VDH will be to provide dental care services to the Denti-Cal eligible children that do not have an established dental home in the selected schools and identified

age range.

Objectives/strategies:

The on-site dental team will provide the following:

1. Perform oral examination and provide dental disease risk assessment 2. Provide health promotion education and disease prevention education 3. Perform preventive procedures including cleaning, fluoride varnish application, and dental sealants 4. Send examination information via secure tele-health system to dentist in clinic for

review and development of a dental treatment plan 5. Coordinate referral and treatment for children that require more than preventive

services

Medical/Dental Collaboration Pilot Project # 2 Given that children begin seeing primary care providers at an early age, these providers have an opportunity to play an important role in facilitating children and families to see a dentist and establish a dental home. Most primary care providers may not feel confident about conducting a dental assessment, and referral may consist of giving a caregiver the name of a dentist without further assistance.

In this pilot project, the innovative strategies will be: Increase primary care provider knowledge, skill and confidence in making dental caries

assessment and providing preventive oral care education.

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Facilitate referral of patients from the primary care provider by assisting the provider in identifying children who have not had a dental visit in the previous year.

Children Now will train pediatricians and other medical and health care providers serving children to use an oral health team to provide caries risk assessment; dental screening, fluoride varnish and referral back to the patient's assigned dental plan/dental home; and work to co-locate dental and pediatric services whenever possible to facilitate referral of children to dentists.

The goal of the medical/dental collaboration is to ensure that all children in the participating medical practices have preventive dental services and have at least one visit with a dentist in the year. This pilot will build the capacity of local programs to carry on this work in the future.

Community Care Coordination and Training Pilot Project #3 By training community health workers and medical providers; any worker that touches families will have current dental knowledge and referral information to the dental plan member services to establish a dental home for children through Motivational Interviewing.

There are four areas in which the Child Abuse Prevention Center (CAPC) will be able to assist the Dental Transformation Initiative implementation in Sacramento and Amador counties:

CAPC has experience and a range of types of training, trainees, and technical assistance; staff expertise in training, curricula development, and on-line and interactive training modalities. CAPC has a sophisticated on-line registration, training delivery, and evaluation system in place.

1. Use the Learning Management System (LMS), which has the capacity to do on-line registration, tracking of trainees and their organization, prompting for fresh-up training, evaluation of training, delivery of on-line courses, and other potential time and cost saving approaches.

2. Develop or use already developed curriculum for an on-line training for staff working in family resource centers and other community and public agencies that is available to staff currently within the agencies and to new hires upon orientation without waiting for a scheduled training. A self-paced, interactive course with pre-post evaluation of knowledge and automatic triggers for updates to all trainees is an efficient way to access the greatest number of people who have contact with eligible families. This will be accessible on a continuous basis to partners and/or expanded to reach additional agency staff to further the access to children and their families. It will be also be combined with in-person training, access to questions and answers, and/or other types of technical assistance.

3. Host additional on-line training for professionals targeted to their expertise such as preschools, childcare providers, foster family agencies, Child Protective Services (CPS), food banks, mental health programs and other family service agencies, etc. Assist with curricula development and converting curricula to on-line, interactive formats, when needed.

4. Conduct Outreach and Care Coordination.

The goal of the community outreach and care coordination is to increase awareness in the community about the need for dental care and to have a uniform message provided by all the community health workers and navigators.

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Performance Metrics The performance metrics for analyzing the success of Domain 1 will be based on data demonstrating an increase in preventive services provided to Medi-Cal beneficiaries ages one (1) through twenty (20) who are continuously enrolled for at least ninety (90) days during the measurement periods.

The performance metrics for Domain 3 include the number of beneficiaries age twenty (20) and under who received a qualifying examination (D0120, D0150, or D0145) and returned for a qualifying examination the following year from the same service office location and the number of beneficiaries ages 20 and under enrolled in Medi-Cal during the measurement period. We will collect data based on:

Annually calculate total number of children served over total eligible Number of restorative services Number using ER baseline and annual General anesthesia: number of children receiving GA

Quality improvement Plan The VDH will aim to achieve the Triple Aim, which consists of: Improving the experience of care Improving the health of populations, and Reducing per capita costs of health care

The Quality Improvement Plan will test out the success of the three pilot projects in achieving these aims.

3.3 Accountability

The LDPP pilot projects will create and manage the Dental Alert System in both counties to ensure issues are responded to in a timely manner involving all partners in the pilot. This will ensure that behind the scenes coordination will happen for the families and children reached in the pilot. The Dental Collaboration Partners will review the Dental Alerts during the monthly meetings.

Sacramento County staff will conduct annual site visits with funded participating entities to review records, pull random charts and records to ensure completion and develop corrective action plans when necessary.

The pilot projects will use the Plan Do Study Act (PDSA) cycles for quality improvement. All participants will receive training in the PDSA process at the beginning of the project. At the beginning of the projects, the partners will meet to develop a workflow plan set up regular monthly QI meetings, and identify checking-in points that will help ensure that beneficiaries are receiving timely and medically necessary care.

1. For the VDH, these quality indicators will include: - Identification of children in the targeted schools that have not had a dental visit in the previous year

- Number of children that need further dental care following the VDH visit - Length of time from date child is first seen to time child is seen at the dentist

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2. For the medical/dental collaboration, quality indicators will include: - Number of children in medical practice that do not have documented visit with a dentist in the previous year

- Number of children that are referred and receive a visit with the dentist within the year

3. For the Community Care Coordination quality indicator will include: - Number of time CHW/navigator gives a dental message to a client or helps client link to dental care

After each project, partners will select QI indicators; develop a workflow plan and determine method of data collection. The Sacramento County staff will work with each team to ensure timely collection of data and help troubleshoot any problems that may arise, develop corrective plan and help to implement it. Sacramento County staff will set up a database for collection of all the reports and indicators required by DHCS and to ensure that the measures meet the DHCS requirements.

Pilot # 1 The Innovative strategy being demonstrated is the incorporation of the VDH system into a Medicaid funded county delivery system. The VDH system of care has been developed and tested in a six-year grant funded proof-of-concept demonstration. This demonstration established that telehealthconnected teams can work with great results and that dental hygienists can safely determine what radiographs to take and place interim therapeutic restorations (ITRs) after being instructed to do so by a dentist. This application for DTI funding would allow development of a VDH system in Sacramento County that uses Denti-Cal billing to pay for the dental treatment provided. It will allow testing of the ability of the VDH system to function and be sustainable in a billing environment.

Although DHCS has adopted regulations that allow providers to bill for services performed using store-and-forward teledentistry as required by AB1174, this is only a portion of the support needed for providers to establish and sustain VDH systems. This model for providing dental care is significantly different than the traditional dental care systems in use. The providers, community sites and communities will require significant help in system design and customization, training, and technical assistance over the grant period before these systems are established and stabilized and they are in a position to be able to continue to provide services using this model in a way that is self-sustaining based on program billing revenue. The activities and resources needed for the required help in system design and customization, initial; equipment purchase, training, and technical assistance are not supported under the Denti-Cal system.

For this project, salaries related to patient care, patient care supplies, and equipment (with the exception of portable equipment purchased in the start-up phase of the project) are part of normal clinical care operations and will be paid by the providers.

The goals of this project will be to demonstrate that incorporating a VDH system focused on children can allow the system to:

Reach many more Denti-Cal beneficiaries than are currently being reached in the geographic areas where this demonstration will take place,

Integrate oral health activities into the environment, activities, and processes of community sites where children already are,

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Apply proven prevention and early intervention procedures in community locations such as schools and pre-school programs,

Establish a continuous presence system where the on-site dental team is present in the community site throughout the school year. This is known to increase awareness and focus on oral health which is critical to support adoption of healthy habits for self-care and tooth healthy diets,

Keep the majority of children healthy on site in the schools and pre-school sites, and importantly verify through the telehealth system that they are healthy. This is possible because the dentist is involved through the telehealth system and can review records and x-rays immediately while the child is being seen.

Refer those children with advanced disease to dental offices/clinics for treatment of those problems, while maintaining on-going diagnostic and prevention services in the community,

Improve the oral health of the children served in this demonstration as measured by incidence of untreated dental caries, signs of pain and infection, and use of the hospital emergency department for dental care.

This project will develop, strengthen and stabilize this system over a three and one-half year time frame and will prepare the counties to have this system continue on a self-sustaining basis, supported by program revenue, after the grant period.

UOP will have the following responsibilities in establishing and supporting this program:

UOP will design and direct the integration of the VDH system. UOP will: o Participate in meetings with advisory groups, o Help participants to design specific delivery systems for after meeting with

participating groups, o Assist providers with specific protocol development for each site, o Train personnel in the health plans, participating provider dental office/clinics and

community sites, o Provide technical assistance over the life of the demonstration, o Assist in collection or analysis of qualitative and quantitative data, o Help preparation reports and recommendations.

UOP planning, system design, and training topics include: o Formation and use of advisory and steering committees. o Planning for community awareness building about the system as it starts and grows. o Selection of target populations for the system and investigation and understanding of

their characteristics, locations, unique needs, and services systems they are involved with.

o Selection or engagement of the oral health providers that will participate and investigation and understanding of their current training, capacity, and training needs for the VDH system.

o Assessment of current agreements in place between providers and other participants and community sites and the need for new agreements. Assistance with modifying existing agreements or developing new ones for the VDH system.

o Assessment of current enrollment and program processes and forms in use by providers and the need to modify or add new components and processes. Assistance

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with modifying existing enrollment and program processes and forms or developing new ones for the VDH system.

o Assessment of provider and community site staffing arrangements and assistance planning appropriate staffing organization and plans for the VDH system.

o Analysis of current provider electronic dental record (EDR) systems and assistance using, modifying, or incorporating new components needed for the VDH sy stem.

o Planning for program evaluation including selection of measures and developing methods for collecting nee ded data.

o Assistance in developing operating protocols and documentation for use in community sites.

o Assistance with economic analysis and forecasting of ROI for providers. o Specific training to various group among providers and community sites on the

following topics: The changing health care landscape, implications for the oral health system. Target populations and partner organizations, including culture,

characteristics, and i ntegrating oral health services. The use of telehealth in the delivery of oral health services in social,

educational and general health systems including the use of telehealth in the delivery of oral health services including, use of cloud-based r ecord system in distributed team environment, and function and communication of telehealthconnected teams.

Legal considerations including HIPAA, consent, scope of practice laws and regulations, telehealth billing regulations, and malpractice coverage.

Operational protocols including arrangements with schools and other community sites, use and arrangement for space, roles and responsibilities of provider staff and school staff, scheduling, communications with administrators, staff, parents and other stakeholders, and infection control in community locations

EDR and Data management issues including using customized components of the EDR system including risk assessment and basic measures, tracking VDH outcomes using additional non-billing procedure codes, and using the EDR for communicating in telehealth connected team practice.

Scientific basis for VDH procedures including scientific basis for examination and treatment planning using telehealth technology, risk adjusted prevention protocols, partial caries removal, and criteria and technique for placing Interim Therapeutic Restorations.

Facilitating behavior change including factors that influence oral health, principles influencing behavior change, and motivational interviewing

Billing practice and strategies and other financial considerations. Training dental hygienists to place Interim Therapeutic Restorations.

Pilot # 2 The innovation being tested is provision of dental assessment and fluoride varnish at pediatricians offices, combined with warm hand-off to dentists. The P roject goals are:

iii) increase in children with an established dental home iv) increase percentage of children who receive preventive dental services v) increased number of referrals to dentists that result in a dental visit.

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The anticipated outcome is increased confidence of pediatricians to conduct dental assessments, and establishment referral system from pediatricians to dentists.

The performance metrics are:

i) number of children that receive dental assessment and fluoride varnish in participating pediatricians offices;

ii) number of successful referrals from participating pediatricians office to dental offices;

iii) number of children in participating pediatricians practices with a visit to the dentist in the previous year;

iv) number of children in participating pediatricians practices who have not seen a dentist in the previous year.

Pilot # 3 The innovation being tested is the use of trauma-informed care to provide navigation/care coordination to families seeking care in emergency rooms for dental problems. The innovation is based on work done in medical care where it was found that people who are frequent users of the Emergency Rooms often have psycho-social problems that may be a result of childhood trauma. By having Health Navigators stationed in Emergency Rooms to provide care coordination, education and assistance with accessing services, the patients are able to take better of them selves and receive appropriate treatment.

The goals of this strategy is to:

i) increase number of children with established dental homes; ii) increase early diagnosis and t reatment of dental caries and prevent complications.

The desired outcome is that there will be reduce the use of the Emergency Rooms for dental problems. The performance metrics will be:

i) number of children that receive care coordination for dental care resulting in a dental visit;

ii) number of referrals made to other social services.

The activities in this project differ from the CMAA activities that do not include education about dental health an d do not take into account other issues that the person may be dealing with that may affect heath and their ability to access services.

3.4 Data Sharing

All participating entities will enter into a Business Association Agreement (BAA) as outlined in Attachment JJ of the M edi-Cal 2020 Waiver Special Terms and Conditions. In order to ensure timely sharing of information, Sacramento County will develop a database system to enable exchange of information. Crucial data that will need to be shared includes:

- Whether a beneficiary has had a dental visit in the previous year - Identification of dental home - Referral information for beneficiaries that require further workup - After referral, whether beneficiary was seen and outcome of the visit

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For the VDH, data from the oral health team will be transmitted to the dentist via a tele-health system.

For the medical/dental collaboration, the participating medical practices will use their Electronic Health Record (EHR) systems to identify children that have not had a dental visit in the previous year. They will coordinate with the Dental plans to identify the dental home for the beneficiary. Following the visit, participating dentists will report these visits and outcomes to the County and Dental Plans for reporting and QI. The Dental Plans are working to open a portal for Sacramento Covered after signing Business Association Agreements.

Each project provides innovative ways to increase the utilization rate in Sacramento and Amador County to accomplish the LDPP goals. The dental plans will be involved in each of the pilot projects to help identify patients that are eligible, and to ensure completion of services and assistance with care coordination and referral. Community linkages will occur through communications sent out by the dental plans to their members. Coordination will ensure that the services being provided are utilized efficiently and that there is no duplication. Coordination will also help with accurate data collection.

The lead and participating entities and other partners will meet on a monthly basis to ensure that milestones are met and to troubleshoot any issues that may come up. MOUs will be developed with participating entities to formalize roles and ensure that expectations for activities and scope of work are outlined. In addition, the Dental Alert System will ensure problems are resolved in a timely manner. All entities will input data into the newly developed Database system that will gather data and also print out useful reports for all partners and for reporting to DHCS.

As described in Section 3, 3.1, 3.1.1, 3.1.2, 3.1.3, 3.2; all participating entities are bringing resources to the pilots, please see the chart in Attachment 2 that shows existing services and the expanded services under the LDPP DTI. As the only county in California with mandatory GMC Denti-Cal, the collaborative will work closely with contracted Denti-Cal plans that have systems in place and contact information to quickly identify eligible patients and verify coverage as well as es

Local Dental Pilot Project Application - California ...€¦ · LIBERTY Dental Plan DHCS Contracted...

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