By Ed Martinez – February 6, 2000
The Department of Health and Human Services reports that over four million children receive their primary health care from Community Health Centers (CHCs). Most of these are low income, minority, and disadvantaged children – children who frequently experience advanced dental disease. Yet less than half of all federally sponsored CHCs have dental facilities. This essay addresses the capacity of one Community Health Center to effectively respond to the tidal wave of early childhood caries now sweeping through our nation’s high-risk communities and consuming scarce resources at alarming rates. I believe that our experience at the San Ysidro Health Center (SYHC) presents a fair overview of the strengths and limitations of CHC dental programs.
SYHC, a Federally Qualified Health Center located in San Ysidro, California-an urban community approximately twenty miles south of San Diego, at the U.S. -Mexico border – is one of 400 community health centers funded by the HRSA Bureau of Primary Health Care to provide basic dental services in dentally underserved communities. This funding allows CHCs to offer community based dental services on a sliding fee basis to facilitate optimal access to essential oral health care.
A unique characteristic of FQHC health centers is their governance requirement that consumers represent a minimum of 51 percent of the board’s membership. This requirement safeguards the community’s pivotal role in defining the mission and focus of CHC services.
SYHC has an operating budget of just over
$17 million and provides a full menu of ser vices, including dental care in a 10-chair dental facility, three neighborhood primary care clinics, a county-wide mental health program for children, adolescents and adults, and a very busy WIC program. Approximately 70% of our 38,000 users are women and children under the age of 12. Latinos represent 85% of our total patient population. Our well-child and WIC pro grams provide services to approximately 5,000 infants and toddlers each month. SYHC has initiated a strategic planning process to redefine the mission of its existing oral health services program to meet the challenge these children present.
Historically, SYHC’s dental program has functioned as our community’s dental safe ty-net provider. By necessity, our dental services have focused on meeting the acute dental needs of area residents by providing walk-in urgent and emergent care as well as scheduled appointments for restorative care. Each month, our full time staff of four dentists and one hygienist provides care to approximately 1,000 low-income, high-risk patients. One-third of these patients are high-risk children between the ages of 6 through 15. In addition, we have experienced increasing demand for “drill and fill” services over the last two years, attributable to an alarming increase in very young children presenting to our dental clinic with advanced stages of early childhood caries.
As experienced front-line providers, our dentists have exhorted our management team to consider the magnitude of this epi demic. According to the 1993-4 California Oral Health Needs Assessment reported by the Dental Health foundation, over one quarter of preschool children have untreated decay and 9 percent of those are suffering from pain, trauma, or infection and are in urgent need of dental treatment. Sixty-six percent of 6-to 8-year-old Hispanic children have untreated dental decay. Half of all school-age children have untreated tooth decay, and 25 percent of those in the minor ity and underserved populations experience 75 percent of the disease burden.
Since the beginning of the community health center movement in the early 1960s, CHCs have demonstrated clearly their effec tiveness in delivering affordable, high quali ty, and culturally competent services to low income, uninsured populations. To provide the full scope of program services required for federal funding (pediatrics, ob/gyn, medicine, social services, and case management),
“In spite of chronic funding deficiencies, CHCs continue to play a key role in improving access to care for low-income, uninsured and underserved populations.”
CHCs have pioneered a number of innovative strategies for delivering services to high- risk, traditionally underserved populations. Conceptually, these we11-established service delivery strategies are ideally suited to effectively address ECC in high-risk communities. Four strategies we have used to improve the health of our community can be readily applied to young children with early child hood caries:
1- Targeting high-risk populations with early intervention initiatives. Federally funded CHCs operate within designated “Medically Underserved Areas” as well as “Health Professional Shortage Areas.” By definition, these geographic areas are pop ulated by high-risk populations experi encing significant access-to-care barriers. Therefore, CHCs have the capacity to deliver early screening and health promo tion programs to high-risk populations that include low-income women, children and adolescents, pregnant teens, the homeless, and frail
2- To address ECC effectively for high-risk children, it is understood that primary pre vention measures must begin between the ages of 1-2 SYHC as well as hundreds of other CH.Cs operate, and collaborate with, WIC and Headstart programs to reach high-risk children in a timely way. Over the past 3- 6 months, SYHC1s WIC program has provided services to an average of 4,000 preschoolers per month. Through our ongoing WIC program, SYHC has established personal relationships with mothers and families that will facilitate the implementation of early dental intervention initiatives.
3- In the world of early childhood develop ment, it is a well-established fact that a multidisciplinary approach is essential to optimize a child’s overall health and
SYHC and many other CHCs are moving towards an integrated approach to delivering pediatric, prenatal, mental health, and WIC services to high-risk mothers, children, and families. Discussions are in progress to collaborate with agencies offering family-support services such – as early child development counseling, parenting skills, and home visitation services. This comprehensive service approach represents an expansion of SYHC’s traditional model of care and builds on the goal of developing a more holistic approach to improving the quality of life for our community.
4- Historically, case management techniques have been well established in CHC High-risk populations (e.g., diabetics, home less, emotionally disturbed, HIV/AIDS) require focused attention, individualized treatment plans, and care coordination. Given the psychosocial and cultural charac teristics of our community, this case manage ment expertise is an essential piece to devel oping effective intervention programs for children at high risk for dental disease.
SYHC has developed several pediatric medicine speciality clinics with our local children’s hospital. These services have allowed our health center to provide on site specialty services that benefited our patients as well as improved the clinical management skills of our primary care providers. This model offers great potential for collaborations between CHCs and the pediatric dentistry community. To develop effective programs for managing ECC, CHCs have a great need for the technical support and leadership skills of pediatric dentists. Because of the national manpower shortage in the area of pediatric dentistry, we must develop innovative strategies for expanding the pool of trained personnel for ECC prevention programs.
To address this shortage, SYHC is working with a pediatric dentist from the University of California at San Francisco, School of Dentistry, to develop a continuing education program for our staff of general dentists. This curriculum will focus on the management of early childhood caries, as well as skills for managing young children in the clinic set ting. Discussions are also in progress for training non-traditional dental providers in early detection strategies, such as screening techniques for pediatricians, nurses, WIC counselors, Headstart personnel, and community outreach workers.
In spite of chronic funding deficiencies, CHCs continue to play a key role in improving access to care for low-income, uninsured and underserved populations. In response to the high demand for acute dental care, many CHC dental programs struggle to get out of the “drill and fill” mode of operation and refocus their professional energies towards a prevention and early intervention approach to community oral health. Unfortunately, given the increasing number of uninsured patients and the alarming increase of dental disease in high-risk communities, CHC dental programs will certainly continue to experience difficulties in meeting the community’s oral health needs.
These difficulties can best be overcome through collaborations between CHCs and pediatric dentists in nearby communities and through the generalized adoption, by both private and public sector dentists, of community-oriented interventions-the kind of interventions that CHCs have developed as they seek to meet the health care needs of disadvantaged children.
Ed Martinez is a resident of El Cajon and former CEO/President of San Ysidro Health Center