From the WSDA News: Access in Action
WSDA member dentists faced tough criticism over the last year. Battles in the legislature threatened to damage the profession’s reputation among the public, with cries about access to care creating a chorus heard over the state. Some implied that dentists were doing nothing to create avenues to access, or worse, were actively thwarting access to care, but we know that’s inaccurate. While we can easily point to programs like Medicaid (Apple Health) and Community Health Clinics as key access resources in the state, there are countless other ways the public never sees. What if these efforts didn’t exist?
And while some of them are sizable events like The Seattle King County Clinic, many others are home-grown, grassroots efforts in tight-knit communities. Additionally, the vast majority of dentists in the state provide some level of free dental care to patients of record, people in need, and those referred to specialty practices from their GP colleagues.
Some, like Dr. Judson Werner of Seattle-King County Dental Society, track their charitable care to the penny, coding all uncompensated care so that he has an accurate year-end tally. Most, however, do not. Dentists are loathe to report the care they donate, many prefer to do work for free rather than try and navigate the labyrinth of Medicaid, and most simply don’t track the uncompensated care they provide. As Dr. Elissa Maynard, president of the Lewis County Dental Society said, “I see many dentists doing lots of free work. Many don’t want to shout it from the rooftops because they want to be discrete about it. Hopefully we can get our people to share more with us. I think if we gather good stories we should share them with any news media possible. It seems like the world can always use more good news.”
So while some say nothing is being done, the reality is quite different. From the smallest component to the largest, dentists throughout Washington are creating, managing, and funding programs designed to help the uninsured and underinsured receive care. From groundbreaking programs like the Swedish Community Specialty Clinic in Seattle, the IDEA Clinic in Spokane, and the Whatcom Project Access program in the Mount Baker District, Washington dentists are working to ensure that those in need can be seen. And although the focus has shifted from children to adults now that the vast majority of the state’s youngest receive care, dentists around the state still offer Give Kids a Smile events in February. We thought we’d reach out to component presidents and executive directors to see what is happening around the state. While not an exhaustive account, this piece serves as an introduction to some of the many programs WSDA members support.
In Small Corners of the State
In reaching out to component presidents, we found extraordinary efforts to deliver access to care all over the state – not just in large component societies. Clark County, for instance, with just 188 members, has seven active programs bringing free care to the area’s poor. Dr. Scott George, Clark County Dental Society’s President, is proud of the work being done in his component to deliver care to the area’s underserved. “We have a full mix of care available in Clark County, it is not 100 percent emergent care based,” he says. “We cover all sides of dental needs through the clinics in the area. You can just Google ‘Vancouver Washington free dental clinics’ and the resources come up.” One such effort is Compassion Vancouver, a faith-based charitable organization that meets twice a year, triaging from a parking lot and then shuttling patients to private practices for care. Another is the Free Clinic of Southwest Washington, which handles emergent needs of the population. Started in 2005, the Free Clinic is completely staffed by volunteer dentists and is open five days a week.
George, an endodontist, volunteers with the New Heights clinic, which also screens patients then refers them to providers willing to take them at no cost. “I get to help out and see patients from the comfort of my own practice. I like that because everyone is comfortable, which isn’t always the case. For instance, when I work out of a van, I don’t have a microscope, which I use for root canals.”
And yet, even in Clark County where they have so many great programs in place, dentists routinely provide uncompensated care on their own – which generally goes unreported. George says, “Honestly, everyone in the component is fairly humble about it, so we don’t talk a lot about the efforts happening, it’s just something that we do. Medicaid dental reimbursement rates are so low that most of the dentists I know would rather do free work than hassle with trying to be reimbursed. You have more control and freedom over what you do, and you feel better about giving the services away than you do about doing the work for .25 on the dollar. Usually the patients are more appreciative knowing that they’re getting taken care of out of kindness.”
In Thurston-Mason Counties, 56 members of the component society (about a third of its membership) donated their time and expertise to the Olympia Union Gospel Mission last year, providing more than $70,000 in uncompensated care to the area’s poorest residents. The clinic, which is funded by many community partners including the component society, opened in 2003. In 2007, local dentist volunteers and OUGM created a network of dentists who accept referrals through the facility and accept case-managed patients in their offices. Dr. Bo Davidson, president of the Thurston-Mason Counties Dental Society, says that other efforts in the area include free screenings at the Children’s Hands-On Museum, where in 2015 volunteers screened nearly 300 children. Screenings this year took place every Saturday throughout the month of February, in conjunction with National Dental Health Month. Davidson says that the SeaMar clinic helps provide access to the un- and underinsured in the Olympia area, and a proposed residency at St. Peters Hospital could have a huge impact on delivering care in the area.
Over in Benton-Franklin Counties Dental Society, members provide free care through volunteer opportunities with the Union Gospel Mission, MTI Vans, and the SmileMobile, but they also partnered with Benton Franklin Community Health Alliance and the Benton Franklin Health Department to present the Medical Dental Health Summit III in early March. Dr. Lee Ostler created the Summit, an interdisciplinary think tank dedicated to understanding the ramifications of oral disease and health. This year they brought world-class medical and dental authorities in to present an Introduction to Dental Oncology course aimed at preparing dentists and hygienists to provide care and dental clearance for cancer and immunocompromised patients. The seminar is sponsored in conjunction with the Tri-Cities Cancer Center. Dr. Christopher Kleist, president of the component society, says, “They will provide training for local dentists so that we will be able to help patients of the Tri-Cities Cancer Center get dental clearance for chemo and radiation within two weeks at no charge. Lee has been instrumental in making the program happen in our area. We’ll learn how to run our practices so that we can always accommodate a patient in need. There is a lot of talk about access to care, and in my mind it really comes down to financial problems for a lot of people. But there are scores of people who don’t even know they need access, and those are the people who are at the greatest risk of developing infections because of dental conditions that can affect their life expectancy — people who are fighting cancer. When it comes to access to care, people like Dr. Lee Ostler are attacking it from a different angle – those people who are at the greatest risk and need advocates in the dental community.”
Kleist is expecting 30 area dentists to be involved in the venture. There are presently 1,100 new cases of cancer diagnosis each year at the Tri-Cities Cancer Center, representing patients from a wide service area in Eastern Washington and Eastern Oregon. He added, “In our part of the state we have community health clinics doing great work in the area. They are wonderful people and they are an amazing resource for the area. We’re fortunate to have a built-in system for the neediest of the needy.”
Pain Free Christmas
North Central District Dental Society is another small group packing a big punch. With just 90 members, the society helps staff the local Lighthouse Ministries clinic, and produces their annual “Pain Free Christmas” program (now in its tenth year) providing free, emergent dental care to those without insurance. Like other components, they also staff the MTI vans and go out in the community, and typically hold a Give Kids a Smile event in February.
The area has fully leveraged the CHC system, incorporating volunteers, student externships, and residents to capacity. NCDDS President Dr. Bruce Wilcox is the Dental Director at a CHC, and knows the challenges of providing care to the uninsured all too well. He said, “I am hiring three new dentists now to do adult care in our area. We’re the only ones doing any adult Medicaid or low income in our area, and we’re hiring into evening and Saturday hours. We were eight chairs a year and a half ago, we’re at 12 now, and we’ll add two more. We also have a dentist who donates a half-day a month at the CHC. We would be open to additional dentists doing that as well.” As part of the Northwest Dental Residency Program they currently have a resident in Wenatchee and another in Chelan helping to expand the clinic’s ability to provide access. Students from Spokane’s RIDE program are in their clinics four months a year, and they also have a popular connection with a extern program through the Arizona School of Dental and Oral Health which funnels an additional 10 students to the Wenatchee clinic, and five to the Chelan clinic a year. Wilcox explains “We’re popular with students because at a lot of the other sites they’ll see 6-8 patients a day, which is much better than they would see in dental school. Here, we make them part of the dentist’s team, and the dentists job is to catch what they can’t get to, so they tend to grow in their ability to see multiple patients faster. We have them seeing 13-15 patients a day. One of our RIDE students reported back that he had performed 200 more procedures than any of his classmates. Our doctors are all in mentorship mode. We’re not here to prove we know more, we’re here to figure out what we can help with and what they can teach us. Students enjoy it here, they’re treated well, and they have a great experience.” Wilcox hopes to establish a foundation so that they can do more in their community, but says, “We’ve considered it but haven’t moved on it. There’s an appetite for the foundation, but not for the extra task of managing it.”
Toothapalooza: A Hit With Kids and the Community
In Snohomish County, everyone seems to know what Toothapalooza is — it’s a hit with the kids. “This year we had 1,000 people show up — the most ever,” said Dr. Scott Westford, president of SCDS. The event brings dentists, musicians, artists and vendors together at the Children’s Museum in Everett for a night of dental-themed activities. Part screening, part public relations, part distribution of hygiene bags (3,000 in February) and all fun, Toothapalooza is just the ticket to unite the community. But Snohomish puts their money where their mouth is, too. Their Foundation has raised and distributed more than $213,000 to community programs like the MTI Vans, Operation School Bell, the Providence General Foundation, and Project Access, which refers dental patients from every single safety net clinic in Snohomish County and sends them to private offices where volunteer dentists see them at no cost.
The Mount Baker District Dental Society is currently developing a clinic to be housed in the new technical academy at Skagit Valley College. Dr. Paul Halgren, president of the Society, said, “As we all know, patients who present in dental pain at the ER are most often given antibiotics and released, but they’re not treating the problem, they’re just medicating it. We’re setting up a clinic they can be referred to in Mt. Vernon. This past year Dr. David Dormans worked one day a week for 15 weeks, and he provided over $40,000 in care.” Over in Whatcom County, dentists and denturists collaborated on the Whatcom Project Access Dental program and provided $42,207 worth of care last year alone. Since the program started in 2011 they have donated about $500,000 in care. Two Veterans Smiles events provided an additional $15,000 in free care, and Whatcom Homeless Connect treated 67 patients, delivering about $15,000 in care.
Spokane Creates Their Own Clinic
In Spokane, the District Dental Society (SDDS) and Dental Society Foundation (SDDSF) literally took access matters into their own hands when they created and developed the IDEA (Inland Northwest Dental Expanded Access) Clinic in 2007. The clinic has gone through some changes to its infrastructure, says SDDS president Dr. Lisa Ellingsen, “As this clinic has grown and changed we have continued to adapt and in order to operate as a safety net for people in the community.”
Dr. Mark Paxton is excited about the changes coming from the clinic, saying, “We’re ramping up the IDEA Clinic – we have now achieved further funding and have hired a part-time a staff dentist. The dental society owns and manages the clinic, which is a unique model in the country. For a professional society to get the funding, organize the project, and actually build a clinic is a model that as a professional society we are very proud of accomplishing. It’s a major step to improving access to care in our community.” This year, Dr. Rachel Williams will be the part-time staff dentist, and she will refer patients out to specialists like Paxton, an Oral & Maxillofacial surgeon. But they built the clinic for another reason as well, says Paxton, “Other than providing care to those who need it most, one of the reasons behind the IDEA clinic was because we wanted to have a mechanism to show that as a professional society we are not just sitting back and doing nothing – we’re actively involved in improving access to care in the Spokane region. It was important for us to be able to show the community what we were willing to do to address access issues.”
Like so many others across the state, Paxton donates care to several programs in the area, including the Medically Complex Patient referral program, Big Table, and the Maxillofacial/Cleft Palate Review Board. Paxton explains what they do, saying “In the Medically Complex Patient referral program, oncologists, transplant, and ENT surgeons can refer patients who need dental clearance to SDDS Executive Director Wendy Johnson, who gets the word out to all of the Oral & Maxillofacial surgeons in Spokane. It helps cancer patients start their chemo or radiation therapy quickly.”
Big Table is a non-profit organization that helps waiters and restaurant staff to get their dentition repaired or reconstructed if need be so that they can get a better job and move from the back of restaurant to the front as a server or host. Clients from Big Table have been able to make huge life changes in Spokane because of the program, and the organization plans to expand to Seattle and Portland next. In Spokane, Big Table has been an effort primarily supported by surgeons and local dental labs.
Finally, the Maxillofacial Review Board/Cleft Lip and Palate program provides largely uncompensated care to children born with cleft lip and palate and other Cranial-Facial deformities. Surgeons, orthodontists, and pediatric dentists in Spokane work together to take care of these children. But the efforts of SDDS go far beyond these programs, says Ellingsen, who notes, “Many of our specialists and general dentists provide care to those in need through programs such as Smile Mobile and Teeth Week. But more privately, our members routinely provide care in their offices, working independently or in conjunction with other non-profit groups and charities, caring for those in need such as local veterans, school children and the homeless.”
Big Components Pack a Punch
Larger components like Pierce County and Seattle-King County Dental Societies have the lion’s share of members and resources in the state, with innovative and successful programs other components are trying to emulate — like the Swedish Community Specialty Clinic in Seattle, and the Pierce County Dentists Care program, which has donated more than $1 million dollars worth of documented care in the past year. The SCSC, perhaps one of the most ambitious clinics of its kind, is a partnership between SKCDS and Swedish Hospital that last year saw close to 2,000 patients, performed 6,721 extractions for $2.3 million in care. Since opening, the clinic has extracted 20,000 teeth, or about $6.3 million in donated care. That’s not a typo: 20,000 extractions. The clinic accepts Medicaid and is funded by Swedish Medical Center and indirectly by the Pacific Hospital Preservation Development Authority – they provide granting to Project Access Northwest, who act as navigators.
Patients present for care at the SCSC after being screened in a local CHC. Dental Director Dr. Noah Letwin says, “Since nearly all of our patients come through the CHC system, they already have a place they can consider their ‘dental home,’ but they may not utilize it. There are some exceptions, of course – we get referrals through the Emergency Departments of the hospital. What people have to understand is that we perform the type of procedures that most general dentists refer out of their office — they are very complex cases. In fact, we initially hoped to staff the clinic mostly with volunteers, but quickly discovered that was unrealistic.” They found that volunteers not only lacked the capability to navigate Swedish’s electronic medical records system, but more often weren’t comfortable doing the procedures that they had to routinely perform at the clinic. To give you an idea of the intensity of the work they do, Letwin says, “We send out residents to Guatemala with Swedish at the end of their residency for a week. While there, they usually extract between 1,200 and 1,500 teeth, which they’re only able to do because of their experience at SCSC. Most teams traveling to that area do half that number. We provide a service that CHC’s don’t have, and we provide training so that our dentists can leave the program and still be able to offer these highly-specialized services. Some of our residents have gone on to CHCs and have been able to bring these services there. One of our residents has gone on to private practice but still volunteers one day a week at SCSC to be the attending dentist.” That’s how the residency program can create an enduring legacy.
But Seattle-King isn’t a one-trick pony, its members are organized and involved in many efforts — from the RAM/Seattle King County Clinic events, Give Kids a Smile events, NW Kidney Center (where volunteers have helped 51 people get dental clearance for transplants) and Tet in Seattle (an event preserving and promoting Vietnamese culture in Seattle), among many others. One of the component’s most far-reaching efforts is the Donated Dental Services program, where dentists can donate services in their own clinic when they have room in their schedule. Werner says, “The program’s focus is on the disabled, elderly and medically compromised patients in the community. They’re funneled through the system, talk with a caseworker who then assigns them to local dentists. It’s a great program because they partner with the labs so that if someone needs lab work or specialty work donated they can arrange that, as well. Since 2000, 1,133 county residents have received $5,200,000 worth of care, with 237 dentists and 105 dental labs participating in the well-organized program. We get to do what we do best: practice dentistry, with the organization handling the case management aspects of it.”
As Werner explains, the Seattle-King County Dental Society Foundation has raised more than $1 million dollars — money that has been used to fund MTI vans, the Provail Clinic, the Union Gospel Mission clinic, and many more events and services aimed at getting services to the people who need it the most. “It’s not necessarily doing dentistry,” he says, “but we do raise money to help programs that provide dentistry to continue to work in the community.”
In the south sound, Pierce County Dentists Care is PCDS’s umbrella program for the component, which has provided more than $1 million dollars worth of free dental care in the past year alone, and that has been the trend for the past several years. Through the program, virtually anyone meeting income criteria needing dental access can be routed through the system and get care. By harnessing a unique combination of community agencies, free events, hospitals, and dentists in private practice, they’re able to serve as navigators to care. Additionally, they organize or participate in eight free dental days a year. Executive Director Cheryl Jenkins says, “We are the dental lead in four “Homeless Connect” days that are managed by Sound Outreach, and we collaborate with Bates Dental Clinic to provide four free dental days. We also partner with Communities in Schools of Tacoma to provide oral hygiene bags and a book about the importance of oral health to every child in the Communities in Schools of Tacoma program. Our goal has been to provide 3,000 oral hygiene bags during the month of February. We also coordinate with any community agency in Pierce County who has identified a person in need of emergent oral healthcare and that does not possess resources to obtain the care. The dental care is provided for free by members of the Pierce County Dental Society.”
Dr. Michelle Green, president of PCDS, explains how the Homeless Connect program grew from one day a year to four, explaining that transportation was often a barrier to care, and one event threatened to overwhelm their community partners. “When we used to just hold the event at the Tacoma Dome there was no way we could treat all of the people in one day, and our philosophy is that we wanted to make it possible for more people to attend while lightening the load on the community health partners, too. By bringing the Homeless Connect events into the schools, we started seeing more families with children.” Now, they have a pool of dentists working at the Bates Technical College in Tacoma taking all of the restorative patients, the Bates denture clinic is open, and kids are helped through community health clinics or the Give Kids A Smile program to be assigned a private dentist long term. Green continues, saying, “It’s not just a one-day treatment for us, like so many of the homeless events are. We really look at it as an opportunity to get people into a dental home, taking into account factors like their location in the county, their transportation and their level of need and following through. Additionally, as we’ve held more of the events the word has spread that they’re really about getting care to those in need, and so a lot of the people who present aren’t necessarily homeless, but just as likely to be the working poor. Anyone is eligible come to be screened, but whether or not you’re going to qualify to be referred to a clinic is strictly income-based.”
Much More Access Around the State
Unfortunately, it’s not possible to talk about every program around the state, and more importantly, we’re just not aware of the thousands of members who are contributing daily to helping solve the access problem in ways both small and large. But we can’t forget the collective power of these efforts, like Dr. Mike Buehler who built and runs a clinic in Yakima that last year saw 807 patients – some of whom took advantage of an innovative program that allows them to volunteer and earn money toward their treatment plan. This year the WSDA is going to reach out to ask you how much you personally provide in uncompensated care. We hope you realize that you’re making an impact, and we want to spread the word to the public.