Participation in the CARES Act Provider Relief Fund policy by dentists in South Carolina's safety net.

OBJECTIVES: The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion to the Provider Relief Fund, allowing for direct payments to health care providers due to COVID-19. Few studies have evaluated participation in the Provider Relief Fund (PRF), and none have specifically looked at dental providers in the safety net. METHODS: We conducted a retrospective, secondary data analysis using a quasi-experimental cohort design of South Carolina dentists who received PRF payments, comparing those who did and did not participate in the safety net. Safety net practice was operationalized as those participating in Medicaid, and whether they provided care in dental health professional shortage areas, or rural communities. RESULTS: Of the 628 dental providers in South Carolina who received PRF payments, 34% were identified as Medicaid providers while 66% did not participate in Medicaid; we found no statistical difference between payments to Medicaid versus non-Medicaid dental providers. Of PRF payments to dental providers participating in South Carolina's Medicaid program, we found no difference between payments to rural and urban providers but did find that practices offering services in dental care shortage areas received less than providers practicing in counties not designated as a shortage area. CONCLUSIONS: The PRF achieved its goal of distributing financial support to providers affected by the COVID-19 pandemic. But without policy imperatives linked to need-based allocations or incentives for PRF recipients to serve safety net populations, we may later learn this was a missed opportunity for PRF.

A Technical Assistance Curriculum for Expanding Sustainable School-Based Oral Health Programs in the Carolinas' Dental Safety Net.

PURPOSE: School-based oral health programs (SBOHPs) provide opportunities to address oral health inequities by providing convenient access points for care. No published guidelines on SBOHP implementation existed. Our work describes how philanthropic, public, and academic organizations partnered to support dental safety net providers with designing comprehensive SBOHPs in North and South Carolina. DESCRIPTION: A multi-sector leadership team was established to manage a new SBOHP philanthropic-funded grant program organized into two phases, Readiness and Implementation, with the former a 6-month planning period in preparation of the latter. Readiness included technical assistance (TA) delivered through coaching and 15 online learning modules organized in four domains: operations, finance, enabling services, and impact. Organizations could apply for implementation grants after successful TA completion. Process evaluation was used including a Readiness Stoplight Report for tracking progression. ASSESSMENT: Ten Readiness grantees completed the TA. A variety of models resulted, including mobile, portable and fixed clinics. Descriptive analysis was conducted on the readiness stoplight reports. Components of the operation and finance domains required were the most time-intensive, specifically the development of policy manuals, production goals, and financial performance tracking. CONCLUSION: The program's structure resulted in (a) a two-state learning community, (b) SBOHP practice and policy alignment, and (c) coordinated program distribution. TA improvements are planned to account for COVID-19 threats, including school closures, space limitations, and transmission fears. Telehealth, non-aerosolizing procedures, and improved scheduling and communication can address concerns. Organizations considering SBOHPs should explore similar recommendations to navigate adverse circumstances.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis.

AIM: To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis. MATERIALS AND METHODS: NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%. RESULTS: The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group. CONCLUSIONS: Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Elevating Oral Health Interprofessional Practice Among Pediatricians Through a Statewide Quality Improvement Learning Collaborative.

CONTEXT: Because of persistent effects of early childhood caries and impacts of dental health professional shortages areas, the integration of oral health in primary care settings is a public health priority. In this study, we explored oral health interprofessional practice (OHIP) as an integrative pathway to reduce oral health disparities. OHIP can include performing oral health risk assessments, describing the importance of fluoride in the drinking water, implementing fluoride varnish application, and referring patients to a dental home. OBJECTIVE: To conduct a formative evaluation of how 15 pediatric primary care practices implemented the adoption of OHIP in their clinical settings. DESIGN: Using an ecological framework, we conducted a qualitative process evaluation to measure the factors that inhibited and facilitated OHIP adoption into pediatric settings. Document review analysis and qualitative interviews were conducted with pediatric practices to contextualize challenges and facilitators to OHIP adoption. SETTING AND PARTICIPANTS: A total of 15 Children's Health Insurance Program Reauthorization Act pediatric practices located in 13 South Carolina counties participated in this study. MAIN OUTCOME MEASURES: Outcomes of interest were the facilitators and challenges of OHIP adoption into pediatric primary care practices. RESULTS: Thematic analysis revealed challenges for OHIP adoption including limited resources and capacity, role delineation for clinical and administrative staff, communication, and family receptiveness. OHIP training for clinical practitioners and staff and responsiveness from clinical staff and local dentists were facilitators of OHIP adoption. Twelve key recommendations emerged on the basis of participant experiences within OHIP, with developing an active dental referral network and encouraging buy-in from clinical staff for OHIP adoption as primary recommendations. CONCLUSION: We demonstrated the effectiveness of a learning collaborative meeting among pediatric primary care providers to adopt OHIPs. This work reveals an actionable pathway to support oral health equity advancement for children through an additional access point of preventive oral care, reinforcement of positive oral health behaviors, and interaction between parent and child for overall health and wellness of the family.

An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality.

PURPOSE: As a means to identify and quantify oral health interprofessional collaborative practice (IPP), we examined participant-described medical-to-dental (M2D) referral networks and how they function across rurality. METHODS: We conducted a cross-sectional survey on the appraisal of IPP referral systems in 2016. Secondarily, we examined if rural health clinics (RHCs) have different experiences with M2D referrals compared to other practice types. Independent variables included geographic and organizational indicators, referral system attributes, and respondent characteristics. Data were coded by Census region and state Medicaid expansion status. Bivariable and multivariable analyses were conducted using SAS. FINDINGS: A convenience cohort (n = 559) from 44 states was examined. Nearly, half (48.7%) reported dependable M2D referral systems. In bivariate analysis, all independent variables were significant except for state Medicaid expansion status. In multivariable analysis, Census region retained significance (P = .0093). Organization type and practice issues with no shows/missed appointments continued to have significance (P < .001 and .002, respectively). Accountable care organizations were over 5 times (5.72, P = .001) more likely than RHCs to report dependable M2D referral systems. Federally qualified health clinics were slightly over 3 times more likely than RHCs to report dependable M2D referral (3.04, P < .001). No differences between RHCs and other private practices were observed. CONCLUSIONS: The importance of IPP continues to be promoted in the current health care environment. Our study demonstrates that, in this motivated study population, M2D referrals can work well, even in rural areas. Organization type, directionality of referral, broken appointment rates, and electronic health information management were all found to significantly impact the respondents' rating on the dependability of an M2D referral process.

Feasibility assessment for using telehealth technology to improve access to dental care for rural and underserved populations.

OBJECTIVE: South Carolina Dental Association members were surveyed on telehealth knowledge, need, and interest in using it for access to care improvements. METHODS: Dependent variables were Medicaid patient population size (less than or greater than 10%), career stage (early to middle and advanced), and National Health Service Corps participation (yes or no). Practice and provider characteristics were screener questions. Data were collected electronically and analyzed with SAS. Descriptive and bivariate analyses were conducted. RESULTS: Most (69.3%) reported some or no teledentistry knowledge. Distribution of needing consults was: endodontics (40.2%), oral-maxillofacial surgery (37.9%), orthodontia (30.7%), periodontics (28.4%), and pediatrics (12.5%). Consultations for diagnosis (72.9%), emergencies (56.7%), and continuing education (53.3%) were most frequently identified telehealth uses. Medicaid patient population size was the only dependent measure with statistical significance. Compared to <10% Medicaid, >10% was more likely to (1) frequently need consults for orthodontics (25.5% vs 43.4%, P = .0043) and pediatrics (5.9% vs 29.0%, P < .0001); (2) use telehealth for children with special health care needs (44.1% vs 65.8%, P = .0017), complex health conditions (54.3% vs 78.1%, P = .0004), conditions exacerbated by unmet dental needs (44.6% vs 65.8%, P = .0022); and (3) use telehealth for extending practice to underserved populations (14.6% vs 33.8%, P = .0004). CONCLUSIONS: Despite need for telehealth knowledge improvement, sufficient interest exists. Further study will determine if demand for teledentistry is in balance with consultant availability. It has been suggested that access to care improvements require capacity expansions in private practices. States will need to engage dental communities determine if teledentistry is an effective solution.

Impact of South Carolina's Medicaid fluoride varnish reimbursement policy on children's receipt of fluoride varnish in medical and dental settings.

OBJECTIVE: We estimated the effect of South Carolina's (SC) Medicaid fluoride varnish (FV) reimbursement policy on children's receipt of fluoride varnish in medical (MFV) and dental (DFV) settings. METHODS: We obtained data from SC Medicaid enrollment and claims files for children ≤ 47 months of age across State Fiscal Years (SFY) 2008-2013 and created a panel dataset of 52,841 children representing 126,464 child-years of observation. Pooled multivariate logistic regression models were estimated to identify factors associated with a higher likelihood of a child receiving one or more MFV or DFV treatments. RESULTS: The FV rates per child-year were 1 percent for physicians and 23 percent for dentists, respectively. The child-year rate for receipt of FV from both a physician and a dentist was less than one-third of one percent. CONCLUSIONS: A policy designed to increase access to FV treatments from physicians and dentists for children up to forty-seven months of age was not successful for physicians; however, the positive findings for dentists were promising.

Prediction of unmet primary care needs for the medically vulnerable post-disaster: an interrupted time-series analysis of health system responses.

Disasters serve as shocks and precipitate unanticipated disturbances to the health care system. Public health surveillance is generally focused on monitoring latent health and environmental exposure effects, rather than health system performance in response to these local shocks. The following intervention study sought to determine the long-term effects of the 2005 chlorine spill in Graniteville, South Carolina on primary care access for vulnerable populations. We used an interrupted time-series approach to model monthly visits for Ambulatory Care Sensitive Conditions, an indicator of unmet primary care need, to quantify the impact of the disaster on unmet primary care need in Medicaid beneficiaries. The results showed Medicaid beneficiaries in the directly impacted service area experienced improved access to primary care in the 24 months post-disaster. We provide evidence that a health system serving the medically underserved can prove resilient and display improved adaptive capacity under adverse circumstances (i.e., technological disasters) to ensure access to primary care for vulnerable sub-groups. The results suggests a new application for ambulatory care sensitive conditions as a population-based metric to advance anecdotal evidence of secondary surge and evaluate pre- and post-health system surge capacity following a disaster.

Place of origin and violent disagreement among Asian American families: analysis across five States.

We examined the prevalence of and factors associated with violent and heated disagreements in the Asian American families, with an emphasis on place of birth differences between parent and child. Data were obtained from the 2003 National Survey of Children's Health, limited to five states with the highest concentration of Asian-Americans (n = 793). Multivariable analysis used generalized logistic regression models with a three-level outcome, violent and heated disagreement versus calm discussion. Violent disagreements were reported in 13.7% of Asian-American homes and 9.9% of white homes. Differential parent-child place of birth was associated with increased odds for heated disagreement in Asian-American families. Parenting stress increased the likelihood of violent disagreements in both Asian-American and white families. Asian-American families are not immune to potential family violence. Reducing parenting stress and intervening in culturally appropriate ways to reduce generation differences should be violence prevention priorities.

Relationship between presence of a reported medical home and emergency department use among children with asthma.

This study examined data from the 2005-2006 National Survey of Children with Special Health Care Needs to assess the relationship among children with asthma between a reported medical home and emergency department (ED) use. The authors used 21 questions to measure 6 medical home components: personal doctor/nurse, family-centered, compassionate, culturally effective and comprehensive care, and effective care coordination. Weighted zero-inflated Poisson regression analyses assessed the independent effects of having a medical home on annual number of child ED visits while controlling for child and parental characteristics, and the differential likelihood of securing a medical home. Nearly half (49.9%) of asthmatic children had a medical home. Receiving primary care in a medical home was associated with fewer ED visits (incidence rate ratio = 0.93; 95% confidence interval = 0.89-0.97). A medical home in which physicians and parents share responsibility for ensuring that children have access to needed services may improve child and family outcomes for children with asthma.

Disparities in dental insurance coverage and dental care among US children: the National Survey of Children's Health.

OBJECTIVES: We sought to understand disparities in dental insurance coverage and dental care among US children by race/ethnicity, urban/rural residence, and socioeconomic status. METHODS: Linked data from the National Survey of Children's Health and Area Resource File were analyzed (N = 89 071). Multiple logistic regression analysis was used to adjust for confounders. RESULTS: A total of 22.1% of US children lacked parentally reported dental insurance coverage in the preceding year, 26.9% did not have a routine preventive dental visit, and 5.1% had parentally perceived unmet need for preventive dental care. US-born minority children were less likely to lack dental insurance than US-born white children; however, foreign-born Hispanic children were more likely to be uninsured. Rural children were more likely to be uninsured than urban children. Children with health insurance were more likely to have dental coverage. Children who lacked dental insurance were less likely to have received preventive care and more likely to have unmet need for care. Compared with US-born white children, all minority children were less likely to receive preventive care. These disparities were exacerbated among foreign-born children. Fewer race-based disparities were found for unmet need for dental care. Only black children, both US- and foreign-born, had higher odds of unmet need for preventive services than US-born white children. Poor dental health was strongly associated with unmet need. Disparities in dental insurance coverage and dental care are also evident by family socioeconomic status. CONCLUSIONS: Poor and minority children were less likely to receive preventive dental care, even when insurance status was considered. Rural children were less likely to have dental insurance than urban children. Foreign birth affected insurance status for Hispanic children and use of preventive services for all minority children.

The prevalence of violent disagreements in US families: effects of residence, race/ethnicity, and parental stress.

CONTEXT: Witnessing domestic violence increases a child's chance of emotional or behavioral problems during childhood and entering abusive relationships in adulthood, even without co-occurring child maltreatment. OBJECTIVE: Our goals were to estimate the prevalence of reported violent disagreements in the homes of US children and to assess prevalence differences by race/ethnicity, residence, and reported parenting stress. PATIENTS AND METHODS: Data were drawn from the 2003 National Survey of Children's Health. Case subjects with unknown gender, race/ethnicity, or residence were excluded, yielding 99660 observations. Disagreements were classified on the basis of how the family deals with serious disagreement. If disagreements involved hitting or throwing, even rarely, the household was categorized as having violent disagreements. Households reporting heated argument and shouting were classified as having heated disagreement. RESULTS: Nationally, 10.3% of children lived in homes with reported violent disagreements. Violent disagreements were most prevalent among black households (15.1%), followed by "other" (12.1%), Hispanic (11.3%), and white (8.6%) households. Urban areas had higher prevalence (10.7%) than did small through large rural counties (8.3%-9.9%). In multinomial logistic analysis, parents living in rural counties were less likely to report violent disagreements compared with those in urban. Black children were more likely to be exposed to both violent and heated disagreements than were white children. Parents reporting high parenting stress had higher odds of violent and heated disagreement than parents reporting less stress. CONCLUSIONS: A substantial number of children are exposed to violent disagreement. Although demographic and cultural factors may also influence disagreement style, parental stress seems instrumental in the development of violent disagreements. Parents who experience difficulty with parenting constitute a high-risk population. Helping parents understand and address child behavior may reduce such stress.