Developing Cultural Competency Through the Community Dental Health Coordinator. Dunn Cumby, DDS, MPH Frank Jones, DDS, MBA

Transcription

1 Developing Cultural Competency Through the Community Dental Health Coordinator Dunn Cumby, DDS, MPH Frank Jones, DDS, MBA

2 Future Dental Graduates need to be Culturally Competent CHANGES IN DEMOGRAPHICS CHALLENGES DENTAL EDUCATION

3 Demographic Trends in the United States. Presented by: Dunn H. Cumby, DDS, MPH The first part of this presentation is based on a report from the Congressional Research Service titled The Changing Demographic Profile of the United States.

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5 The U.S. Population The current estimate of the U.S. population is million. The U.S. population has more than doubled since 1950 when it was million. The U.S. population is getting BIGGER, OLDER and MORE DIVERSE.

6 The U.S. is getting BIGGER: The U.S. accounts for 4.5% of the world s population. This population has increased by 103% since In comparison Germany and Italy grew by only 21% and 30% respectively. Many of the Eastern European countries have experienced reductions in their populations.

7 Getting Bigger Due To: Increased births Decreased deaths Increased net immigration The Census Bureau projects the U.S. population will reach 440 million by 2050

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9 Fertility Rates: U.S. total fertility rate will actually remain at or above replacement level (2.1 births per woman age 15-44) through In contrast, in much of Europe and Canada, fertility rates are below replacement level and not expected to increase.

10 Immigration: Net immigration rate has been and is projected to be positive (with in-migration exceeding out-migration) for the full century (1950 to 2050). Net immigration will continue at higher rates than currently observed.

11 The U.S. is Getting OLDER: Rapid population aging since 1950 Drastic increase of persons 65 and older By year 2050, the percent of elderly aged 80 and above will be the most populous age group 32.5 million persons or 7.4% of the entire U.S. population.

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16 The U.S. is getting MORE DIVERSE Racial and ethnic diversity is influenced by two major factors: Immigration Different rates of fertility, mortality, and other factors within racial and ethnic groups

17 Hispanics are now the largest ethnic group in the U.S. Numbering over 35 million or 12.6% in 2000 Annual growth rate of 1.5% Expected to grow to 30.2% by 2050, approaching one in every three persons. Characterized by second generation Hispanics, i.e., children of Spanish-speaking immigrants, who are coming of age as the white majority population is aging.

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19 Implications for Health Care Changes in racial and ethnic composition of the population have a profound effect on the health care needs of the population. There are observed differences in how different ethnic groups use health services. There are observed differences in the types of care sought and utilized by race and ethnicity.

20 Approaching Cultural Competence in Dental Education The current demographic composition of dental schools does not reflect that of the U.S. population. Current and future students must be trained to serve a diverse population, and efforts must be continued to increase the representation of URMs in dental schools.

21 Cultural Competence The entire dental team must be culturally competent, not just the dentist as the profession moves forward. Hygienists, dental assistants, as well as new initiatives in work force models must be considered. The ADA has piloted such an initiative, the Community Dental Health Coordinator (CDHC). This new member of the dental team is a community health worker with dental skill sets.

22 Rural, Urban and Native American sites CDHC new Dental Workforce model was piloted by Oklahoma, UCLA and Temple. Oklahoma implemented the Rural Site. Some of the facilities that we partnered with were already externship sites for our Senior Dental Students. (4 weeks > 8 weeks) The facilities recruited the CDHC students from their communities.

23 CDHC Clinic Locations by County and Selected Characteristics Data is based on the county, not the town Town County FQHC/ Tribal/ IHS Population Density 1 (persons per square mile) Median Household Income 1 % Below Poverty level 1 Unemployment Rate 2 State of Oklahoma N/A 54.6 $41, % Ada** Pontotoc Tribal 52.1 $36, % 4.3 Battiest* McCurtain FQHC 17.9 $29, % 8.9 Clayton** Pushmataha FQHC 8.3 $27, % 6.4 Fairfax Osage FQHC 21.1 $43, % 6.8 Konowa Seminole FQHC 40.3 $31, % 6.7 McAlester Pittsburg FQHC 35.1 $37, % 5.1 Nowata Nowata FQHC 18.6 $36, % 6.9 Okmulgee Okmulgee Tribal 57.5 $35, % 8.1 Pawnee Pawnee IHS 29.1 $40, % 7.1 Stigler Haskell FQHC 22.1 $35, % 5.8 Wetumka Hughes FQHC 17.4 $30, % 7.9 Wewoka Seminole IHS 40.3 $31, % 6.7 * This site has two CDHCs from cohort 1 ** These sites have one CDHC from cohort 1 and one CDHC in training from cohort 3 Sources: 1 U.S. Census Bureau: State and County QuickFacts. Data derived from Population Estimates, Census of Population and Housing, Small Area Income and Poverty Estimates, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits, Consolidated Federal Funds Report Last Revised: Friday, 03-Jun Bureau of Labor Statistics. Unemployment Rates by County, Not Seasonally Adjusted, Oklahoma August Bureau of Labor Statistics. Unemployment Rates by State, Not Seasonally Adjusted, August

24 Cohort 1 Program Completion Left to right: Courtney Roberts, Kathy Mathews, Kimberley Cave, Jessica Johnson, and Melissa Tyler 24

25 Oklahoma CDHC Trainees Six trainees started in Oklahoma with Cohort 1 Classes started March 16, 2009 All were recruited from FQHCs in rural Oklahoma Stigler / Haskell County Fairfax / Osage County Clayton / Pushmataha County Tishomingo / Johnson County Battiest / McCurtain County (2) Five students graduated and four remain active as CDHCs 25

26 Melissa Tyler, Cohort 1: No dental experience whatsoever. Now the Dental Clinic Manager at Kiamichi Family Medical Center, Battiest, OK. Responsible for day-to-day operations. Coordinated facility's transition to electronic health records and digital radiography. Actively completing prerequisites for DDS program at OUCOD.

27 Cohort 2 Program Completion Left to right: Melissa Welch, Misty McClain, and Angela Black 27

28 From the Community, For the Community 28

29 Angela Black, Cohort 2: An experienced Expanded Function Dental Assistant at Chickasaw Nation Medical Center, Ada, OK CDHC training expanded foundational knowledge, increased understanding of dental concepts and enhanced clinical skills. CDHC Community Health Worker training positioned her for current Services-At-Large Coordinator position in the Chickasaw Nation Health System. Identifies and assesses health care needs for tribal members across the country. Identifies local health resources and helps navigate them through the system. Future goals include hygiene school at OUCOD.

30 Cohort 3 at CDHC Kick-Off Left to right: Regina Weaver, Lisa Lynch, Victoria Baker, Regina Turner, Amber Cranford, Jacqueline Ramirez, Bonita Baker, and Nicole Singleton 30

31 Oklahoma CDHC Trainees Eight trainees started in Oklahoma with Cohort 3 Classes started March 28, 2011 They were recruited from FQHCs, Tribal, and I.H.S. facilities in rural Oklahoma Wetumka / Hughes County Stigler / Haskell County Clayton / Pushmataha County Ada / Pontotoc County Chickasaw Nation Pawnee / Pawnee County I.H.S. Nowata / Nowata County McAlester / Pittsburg County Konowa / Seminole County 31

32 Nicole Singleton, Cohort 3: Entered program as Dental Clinic Manager at Morton Comprehensive Health Services, Tulsa, OK. Morton is a large FQHC with five locations, including one that serves a predominantly urban African-American community, a homeless dental clinic and a rural facility in Nowata County, OK. Strong administrative and community outreach skills at program entry, but CDHC training added strong clinical skills. Now serving as Billing Coordinator for ALL Morton health services, but maintains CDHC community outreach activities. Future goals include hygiene school at OUCOD.

33 Proposed CDHC Evaluation: A Series of Case Studies Based on clinic goals for utilization of their CDHC, including: Increased Dental Service Capacity Increased Dentist Productivity Increased Community Access to Oral Health Care Increased Access to Care for Specific Sub-populations Decrease in Missed Appointments Increased Clinic Revenue / Financial Sustainability Improved Oral Health Outcomes 33

34 CDHC PILOT PROGRAM EVALUATION CASE STUDY SUMMARIES: July 2013

35 Case Study 1: Addition of CDHC to Dental Team With the addition of the CDHC in 2011, the clinic saw increases in billable procedures. 2,307 procedures in ,066 procedures in 2010 The total care value of services provided increased. $231,551 in 2011 $ 91,399 in 2010 Services provided within the scope of CDHC practice increased. 2011: 704 procedures; $25, : 281 procedures; $ 8,470

36 Case Study 5: Elementary School Outreach During 6 screening events, 139 children received dental screenings. Screenings included: Oral health education Oral hygiene instruction Dietary recommendations Oral health assessment Triage for follow-up restorative and preventive care Recommendations for follow-up care were sent to parents/guardians. Due to the rural geographic area in which the clinic is located, it is evident that a barrier to access remains the inability to transport the children to the clinic.

37 Case Study 83: Tom Joyner Outreach 15 patients between ages 16 and 72 received dental screenings and preventive services. Estimated value of services provided = $7,201. CDHC services included: Prophylaxis Radiographs Consultation services Dentist services included: Oral evaluations Restorative services Oral surgery services Palliative treatment of dental pain

38 Case Study 8: Diabetes Clinic Over a nine-month period, providing dental services only one day per week, the CDHC served 114 patients in the diabetic clinic within this community health center. The total care value of services provided to patients seen in the diabetes clinic and brought into the dental clinic by the CDHC was $45,800. Billable services provided by the CDHC alone generated $13,922. Billable services provided by other dental providers equaled $31,878. Average value of care provided to a patient equaled $402. The CDHC specifically arranged appointments for patients at the diabetes clinic. Rate of missed appointments for diabetes clinic patients was zero. The overall rate of missed appointment among patients seen at the dental clinic is 18%.

39 Case Study 72: Patient Satisfaction Survey Feedback from patients about the CDHC was positive overall. Two-thirds (68.3%) were extremely satisfied. One-third (31.7%) were satisfied.

40 Introduction to the Community Dental Health Coordinator (CDHC)

41 Frank Jones, DDS WHAT IS CULTURAL COMPETENCE?

42 CULTURAL COMPETENCY: DENTISTRY AND MEDICINE LEARNING FROM ONE ANOTHER DEN 7157 Frank Jones, DDS, MBA Mildred A. McClain, PhD September 12, 2011

43 Unequal Treatment: A Report of the Institute of Medicine Congress requests IOM assess differences in type and quality of health care between minorities and nonminorities. Study ascertained 1. Extent of racial and ethnic differences in health care that are not otherwise attributable to known factors such as access to care (ability to pay or insurance coverage)

44 Unequal Treatment: A Report of the Institute of Medicine Study ascertained (cont.) 2. Evaluate potential sources of racial and ethnic disparities in health care, including the role of bias, discrimination, and stereotyping at the individual (provider and patient) institutional, and health system levels; 3. Provide recommendations regarding interventions to eliminate health care disparities

45 Unequal Treatment: A Report of the Institute of Medicine IOM Study linked three factors unrelated to health care access to the differences in treatments and outcomes between minorities and nonminorities. Differences were due to: A) Patients B) System Factors C) Providers

46 Unequal Treatment: A Report of the Institute of Medicine Among the diseases the study committee reviewed were cardiovascular diseases, in which there were pronounced differences in treatment regimen associated with worse outcomes based on racial and ethnic differences. Similar findings suggested differences in the treatment for cancer, diabetes, end stage renal disease, kidney transplantation, and HIV infection.

47 Unequal Treatment: A Report of the Institute of Medicine Two Recommendations: Health Care Provider s awareness of disparities needs to be increased, and Cross Cultural education needs to be integrated into the training of all current and future health professionals.

48 A Growing Awareness of Cultural Issues in the Delivery of Health Care Increased attention on cultural issues and how they influence and impact upon the delivery of health care grew during the 1990 s. WHY??

49 A Growing Awareness of Cultural Issues in the Delivery of Health Care WHY increased attention to multicultural issues in healthcare??

50 A Growing Awareness of Cultural Issues in the Delivery of Health Care Why Increased Interest--- DEMOGRAPHICS increased numbers of minorities and declining population of European descendants

51 A Growing Awareness of Cultural Issues in the Delivery of Health Care The IOM study points to how individual provider bias, racial attitudes, and stereotyping, no matter how subtle, impact on the treatment of minorities. As a result, Liaison Committee for Medical Education has developed accreditation standards that encourage medical schools to incorporate coursework in cultural competency in the curriculum.

52 A Growing Awareness of Cultural Issues in the Delivery of Health Care 2 Standards: A) Faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. B) Medical (dental) students must learn to recognize and appropriately address gender and cultural biases in themselves and others and in the process of health care delivery.

53 A Growing Awareness of Cultural Issues in the Delivery of Health Care What is cultural competency? Cross defined cultural competency as: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals to work effectively in cross-cultural situations.

54 Educating Students on How to Understand Race, Culture and Ethnicity in Practice The Society of Teachers of Family Medicine wrote a report in 1996 stating the curriculum for students should : Develop appropriate attitudes in students as moral and ethical obligations to challenge racism, classism, and other forms of bias and prejudice in the health care setting, and Promote recognition of the student s own biases and reactions to persons from different minority, ethnic, and sociocultural backgrounds

55 Educating Students on How to Understand Race, Culture and Ethnicity in Practice 1978: Kleinman et. al., recognized traditional biomedical solutions could no longer solve major health care problems such as patient dissatisfaction and inequity of access of care. Therefore: It was shown only through a keen appreciation of culture could treatment lead to a satisfactory outcome.

56 Educating Students on How to Understand Race, Culture and Ethnicity in Practice 2002: Green et al. discussed the importance of social issues in care for patients of all cultures. Students learn how cross-cultural factors influence the presentation of symptoms by questioning patients about the influences of social stressors and support networks, changes of environment, levels of empowerment, and literacy.

57 Educating Students on How to Understand Race, Culture and Ethnicity in Practice M.M. DeVan D.D.S., Professor of Prosthetic Dentistry and Chairman of the Prosthetic Department. a University of Pennsylvania, Philadelphia, Pa., USA 1940 s: MEET THE MIND OF THE PATIENT BEFORE YOU MEET THE MOUTH.

58 Educating Students on How to Understand Race, Culture and Ethnicity in Practice 1996: The Society of Teachers of Family Medicine described the attitudes, knowledge, and skills that a core curriculum should develop in students and residents. The Curriculum should develop appropriate attitudes in students as a moral and ethical obligation to challenge racism, classism, and other forms of bias and prejudice in the health care setting and promote recognition of the students own biases and reactions to persons from different minority, ethnic, and sociocultural backgrounds.

59 Educating Students on How to Understand Race, Culture and Ethnicity in Practice Consensus: Developing communication skills, both verbal and nonverbal, and working collaboratively with other health care professionals in a culturally sensitive manner become critical in the development of the student.

60 Unequal Treatment in the Context of Dentistry Surgeon General s Report- Oral Health in America: A Report of the Surgeon General, did find that there were disparities in oral health based on race, culture, and ethnicity. Thus, if dentistry is to reduce oral health disparities related to race and ethnicity, dentistry will also need to recognize how its systems of care and its individual practitioners are influenced by bias, stereotyping, and beliefs about minorities.

61 Recommendations Summary of the IOM committee s recommendations: A) Schools rethink their institutional policies and systems to make sure they take into account cultural differences of their patients, students, and staff and reexamine their curricula..

62 Recommendations B) Increase Service-learning opportunities provide students and residents with Community based assignments that can deepen and enrich awareness. C) Improve diversity for dental schools by increasing the numbers of underrepresented minority faculty and students can lead to a learning environment more apt to consider the effects of bias, ethnicity, and cultural issues in the provision of care.

63 Questions? Reference: Formicola AJ, Stavisky J, Lewy R. Cultural Competency: Dentistry and Medicine Learning from One Another. J Dent Educ 2003;67(8):

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