Medicaid Eligible Populations with Early Childhood Caries

Executive Summary

The central aim of this project was to help primary care providers (PCP) assist rural area Medicaid eligible pediatric populations by identifying those who were at high risk for developing or had already developed early childhood caries (ECC), a cause of often long term health and dental problems. To accomplish this objective, this project: (1) researched literature discussing the pervasiveness of ECC in poor rural communities; (2) ascertained local high risk target populations; (3) evaluated the reported effectiveness of Caries-risk Assessment Tool (CAT) use in rural PCP office well/ill-child visits; and (4) over a three month span in one PCP office, implemented flat fee Rural Health coded CAT routines in order to provide referrals to dental professionals for appropriate treatment.

The results of this project were used to identify the PCP’s initial knowledge base of ECC causative agents, risks, prevention methods, and treatments. Results from the PCP using CAT were also used for identification of at-risk patients, in order to assist in early determinations of appropriate dental intervention plans as well as the immediate generation of referrals for treatment. Finally, results surrounding clinical and preventative guidelines were used to provide support for the PCP as it: (1) administered CAT during routine office visits, and (2) educated caregivers about the proper preventive measures for their children’s dental health.

Results of this project indicate that PCPs can initiate and sustain CAT administration in their routine well/ill-child office visits for Medicaid eligible rural pediatric populations. Through this project’s investigation, PCPs are recommended to invest the calculated 5 to 7 minutes per routine office visit to prevent this population’s high risk of developing and/or not treating ECC. Failure to make this incremental investment represents serious and long-term costs to these patients, their families, and the communities served by PCPs.

Abstract

This project was designed to measure and improve screening for early childhood carries (ECC) in Medicaid receiving children aged 12 months to 13 years by integration and use of the Caries-risk Assessment Tool (CAT) in a rural primary care provider (PCP) office. PCPs have greater access to medium and high-risk Medicaid eligible children than do most dental professionals, and so occupy a prime position to promote their better dental health. Utilizing a convenience sample from the Rolla Family Clinic, within a three month period following implementation this project achieved: (1) 50% improvement in screening rates through utilization of the CAT by PCPs; and (2) 75% referral of medium to high-risk children based on CAT assessment to a dentist for treatment. This project’s results demonstrate that the CAT utilized by PCPs is an effective and inexpensive method for the early diagnosis, treatment, and referral of children with ECC, or at high risk of developing ECC. As such, PCPs serving rural Medicaid pediatric populations are recommended to consider adding CAT to their routine office visit protocol.

Economic Variables

While medical staff at RFC did not specifically request that caregivers indicate their economic condition during visits, it is reasonable to conclude from the literature that being on Medicaid is by itself an expression of a high-risk factor. Numerous caregivers stated they didn't know Medicaid covered dental care, which at least implicitly suggests evidence that economic issues form the very basis of the project and how CAT administration provides an effective prevention and remediation strategy.

Political Variables

As with the economic variables noted, while medical staff at RFC did not specifically request that caregivers indicate if they understood the state funding mechanics of Medicaid, and how it compares with other states, it is reasonable to conclude from the literature that being on Medicaid is by itself an expression of high risk status. Numerous caregivers stated they didn't know Medicaid covered dental care, which at least implicitly suggests evidence that political issues form a nexus to questions of access adequacy, and why CAT administration provides an effective prevention and remediation strategy.

Expected and Actual Outcome Gaps

This project was designed with what were anticipated to be three highly accomplishable objectives. The core motivation underlying this aim was to provide PCPs with assessment data indicating clear opportunities to provide maximum positive impact for high risk pediatric populations. Using a simple administrative tool (CAT) requiring no sophisticated technology to run, and no software savvy office personnel to maintain and sustain, all three expected outcomes were met. Since ECC is the most common chronic disease among children, and Medicaid eligible populations are identified as subject to high risks of ECC and other serious health conditions (Bugis, 2012), this project’s successful implementation of “low barrier” objectives were therefore consistent with promoting positive health outcomes.

The one deviation noted between project proposal and outcome occurred where the proposal stated that all electronic data collected would be encrypted, whereas the files were stored on a secured server. This deviation was deemed minor since it did not affect the project’s primary objectives.

Unanticipated Consequences

Although this project represented imposing a new responsibility not traditionally seen as falling under the PCP umbrella, measurable degrees of responsiveness to implementation and maintenance during the three-month trial was evidenced by all outcomes being met. While PCP staff resistance to CAT administration has been noted by Close, Rozier, Zeldin, & Gilbert, 2010, as a significant barrier to successful implementation (as cited in Revels, Cruz, Cheung, Carver, & Krol, 2013), RFC office and medical staff have universally and expressly sought assurances that this project continues beyond its initial phase. An unanticipated consequence of the project, which brought no additional fees for CAT administration to RFC, is an office reported increase in its “esprit de corps,” signaling continued use of assessment and referral systems to local dentists for appropriate treatment.

Budget Deviations

There were no budgetary deviations between planned and actual expenditures by project completion.

Recommendations

This project’s scope was limited to exploring the effects of CAT administration over three months in one PCP office serving Medicaid eligible pediatric populations living in rural Missouri. The relatively small patient population (154) and particular racial and ethnic mix of those studied would suggest possibly different outcomes in other PCP offices located in other states’ rural settings. In particular, while the literature indicates that low income minority populations are at highest risk of developing or having ECC, a substantial majority of subjects studied here were Caucasian non-Hispanic (77%). The almost universally positive response received from both caregivers and staff here strongly recommends other PCP offices serving Medicaid eligible pediatric populations with different racial and ethnic percentages conduct their own pilot projects focused on this need.

Sustaining this project beyond its first three months is anticipated, largely because initial staff education and training represented the largest resource demand. After initiation, weekly staff meetings ensured consistent application of CAT administrations, and provided a unique forum to deepen discussion on ECC and a host of other community health and patient related topics. It was reported that intra-office rapport increased generally, so that staff recommended what are anticipated to be helpful adjustments to the project moving forward, including: (1) posting quarterly results of CAT administered referrals; (2) calling caregivers with a friendly reminder 24 hours before their dentist referral appointment; and (3) calling caregivers 24 hours after their dentist referral appointment to further the importance of regular dental follow-up.

Expanded telephone call protocols and weekly office meetings are reinforcement strategies believed to help not only the pediatric patient, but also the caregiver (who feels like the PCP cares for their child’s entire health and well-being), the dentist (who feels more essential to the patient’s integrated health plan), the PCP (who feels like there are solid, ongoing reasons to continue the CAT administrations and referrals), and non-medical staff (who best support health care teams when they understand and participate in making a positive difference in children’s lives). It takes an integrated and caring team to offer the best help in preventing and reducing the serious and enduring effects of ECC in high risk pediatric populations. This project was designed to further that core message and provide a simply means by which other PCPs may replicate its outcomes in their communities.

References

Close, K., Rozier, R. G., Zeldin, L. P., & Gilbert, A. R. (2010). Barriers to the adoption and implementation of preventive dental services in primary medical care. Pediatrics, 125(3), 509-517. doi:10.1542/peds.2009-1008

Revels, M., Cruz, K., Cheung, K., Carver, L., & Krol, D. (2013). Providing preventive oral health care to infants and young children in Women, Infants, and Children (WIC), early Head Start, and primary care settings (Synthesis Report September 2013). Retrieved from Robert Wood Johnson Foundation website: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407854