Methods/Implementation Plan for Early Childhood Caries (ECC)

Setting

The setting for this project will be Rolla Family Clinic, a private practice setting with four PCP providers (three family nurse practitioners and one medical doctor), and two nurses. The practice is in a rural area in City/State. The number of Medicaid patients comprises 40% of the total number of patients (700) visiting the practice. Fifty percent of the children between the ages of 12 months to 13 years are Medicaid recipients.

Participants

There are two types of participants for this study: the PCP providers who will receive the education (three family nurse practitioners and one doctor), and the patients (30 patients on a monthly basis) who will be recipients of the new screening tool, education, and referral program.

All PCP providers within the practice setting will be included to receive education regarding the problem of early childhood caries (ECC) and training on how to administer the CAT. Their participation will be involuntary, as this study’s implementation is going to be incorporated as a new protocol throughout the practice.

The patients participating in the study will be the patients that are most at risk for ECC. They will be of low socioeconomic status and Medicaid recipients. Since ECC is a childhood-specified condition, the participants will be between the ages of 12 months and 13 years. Each time the patients visit the office for a wellness visit, the CAT and accompanying educational materials will be administered during the visit. The participation of the patients will be involuntary, as the incorporation of the CAT protocol will become part of wellness visits.

Sampling

The inclusion criteria will be Medicaid recipients between the ages of 12 months and 13 years visiting the clinic for their wellness visits. The exclusion criteria will be children younger than 12 months or older than 13 years and are not Medicaid recipients, and Medicaid recipients visiting the clinic for a sick visit.

Barriers to Implementation and Sustainability

There are several barriers to implementation from the viewpoint of the PCPs and the patients. In the following bulleted points, the barriers to implementation from the viewpoint of the PCP are discussed:

• PCPs are already burdened by many duties and a lack of time; incorporating another duty may not be feasible or may be met with resistance.

• Implementing the CAT does not guarantee that a PCP will then engage in any type of oral care with the patient or that the PCP’s referral to a dental professional will result in a dental visit.

• PCPs cannot ensure patient adherence to dental referrals

• Caregivers’ lack of understanding of oral health best practices, or lack of ability to implement them.

• Resistance from PCPs to providing care that they may not believe is their responsibility.

• PCPs not fully understanding the risks of ECC or identifying patients truly at an increased risk.

Medicaid recipients often have challenges in their lives that could act as barriers to medical and dental care. The following aspects reflect this population’s typical challenges and how this culminates into barriers in the implementation and sustainability of the CAT protocol:

• Medicaid could refuse to reimburse for the part of the visit to a PCP that focused on dental care.

• Patients could refuse to go to a dentist for fear of accumulating bills they cannot pay or because of a fear of dentists in general.

• The lack of availability of dental professionals in the area willing to accept Medicaid patients and/or new patients.

• The patients may not have transportation to get to the dentist's office.

• A lack of fluoride in well water or bottled water can present ongoing challenges to dental health.

Potential Benefits and Risks to Subjects

The benefits and risks to the participating subjects for this study will be described in terms of the PCP providers and the patients. First, the potential risks will be discussed, followed by the benefits to both provider and recipient. The discussion will reveal that the risks are minimized within this study, and the potential for positive outcomes as a result of the implementation of the CAT protocol far outweigh the risks.

The risks for the PCPs are the investment of time it will take for the training and education phase of this study. Healthcare workers, even those within a private care practice or small clinics, are often overworked, and any extra time investment might put temporary stress upon the clinician, as well as all the physical, emotional, and mental challenges stress could potentially induce.

However, the benefits for the clinician outweigh the stress the training process could inflict. The CAT is designed specifically to address issues such as ease of implementation, requiring only a minimal amount of training time for PCPs (AAPD, 2006). As the AAPD expressed, the protocol is also designed to streamline efficiency within the PCP’s practice. The protocol implements a sound system where patients at risk for ECC are easily identified, is easily implemented in a variety of settings, provides literature, anticipatory guidance, and recommendations as provided to caregivers, and allows the facilitation of important dental health discussions, as well as a system for tracking patient progress. In the end, although there is some time investment, in the beginning, the program is a time saver as the protocol is implemented and utilized.

On the patient side, the parents of the children could potentially be upset if they learn that people in their financial position are being provided the intervention and not people with more financial means. Moreover, they might feel a sense of frustration, especially if they know what their child needs, but believe they unable to deliver it to them because of their financial position. However, these issues will be addressed by making certain they are referred to a dentist that agrees to see new Medicaid patients and educating them about Medicaid benefits. The benefits patients and their parents will receive as a result of their participation in the study are increased knowledge to help the health of the child, the children’s increased knowledge in their oral health, referrals to dental professionals that will be able to address ECC in the patient, and improved health outcomes.

Ethical Considerations

Ethical guidelines are often the basis of state and federal regulations regarding the practice and care of patients. HIPAA will be applied to this study in all circumstances. Patient confidentiality will also be maintained according to laws and regulations. Also, to protect the patients from information theft, all patient files and files pertaining to this study will be kept in a double-locked file drawer. Only approved personnel will have access to the files. The files are locked when the clinic closes for the night in their file cabinet drawers in a locked facility, and the facility has a security system.

Also, the purposes of this study align with ethical considerations, which are improved healthcare outcomes for children from low SES families. Every step of the study seeks to improve the quality of care to the patient, improve practitioner knowledge, and improve patient health outcomes. All potential risks associated with the study are addressed and minimized to improve the success of this study and minimize harm to participants.