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Washington State Dental Association

2011 Citizen of the Year, Dr. Tim Verharen

Each year, the Washington State Dental Association bestows its highest honor on a member nominated for excellence in civic activities. Past recipients have done everything from founding dental clinics here in the northwest to bringing modern dentistry to Haiti. Dr. Tim Verharen, this year’s recipient, did something a little different: he designed an innovative, forward-thinking community program that helps deliver dental care while asking the patients to give of themselves.

Service With A Smile…and a twist
    The program isn’t designed to solve the traditional access dilemma: it’s not for emergent care, it’s not even designed for ongoing care (although, depending on the length of the treatment plan, that could be the de facto result). Verharen says, “It’s not just about access to care, it’s about how our problems have been defined. For instance, we say we have an access to care issue, but I would say it’s not the only issue. More importantly, we have an accountability issue and a value issue. The value issue is an old bugaboo for dentistry — how long has that not been there? Do people value what we do? No, we have to educate them on that. Accountability is what the program is really geared to.”
    But how to do that? One night in 2002, as he and his wife Juli returned from an educational forum on the ferry back to Bremerton, they were brainstorming about their next homework assignment: to design a social program they could give back to their community, and thus Service with a Smile was born. Verharen was a director at Penninsula Community Clinic, where they saw mostly pediatric patients (with the occasional adult emergency case), but no ongoing care available to adults. He wanted to devise a program that would capitalize on the work ethic and values he knew existed in the community, and harness them in a way that would give back and satisfy the need for access to dental care. And it was important to Verharen that participating dentists be able to work in their offices, as opposed to out in the field, saying “If you take a dentist outside of his office, he’s not very productive. He or she does best in the office with his own materials and his own team. When they bring a mobile unit or they all go to one office to get the work done — they’re doing great stuff, but they can’t be as efficient.”
     That night on the ferry, they outlined what would eventually become Service with a Smile, a breakthrough program that helps low income people in Kitsap county get access to dentistry. There’s a caveat — in order to receive dental care, each participant has to give back to the community by volunteering at any one of 16 local, approved non-profit organizations like food banks, the YMCA and Habitat for Humanity. The program’s maintenance is a little tricky, involving tracking hours, depositing co-pays into a local credit union (co-pay fees are used to cover the administration of the program, participating dentists receive no reimbursement for services), and earning enough hours to pay-as-you-go for services rendered, but that’s exactly the beauty of it — these patients are paying — with their time and hard work. Verharen kicked off the program in 2002 while at Penninsula, passed the program off to Leadership Kitsap for a little more than a year — who used their assets to help develop marketing and collateral materials on behalf of the program. Penninsula took the program back for another year until 2004, when Verharen took the program with him to his private practice, where he has been the motivating force ever since.

The value of dentistry
    His seven year stint at Penninsula Community Clinic did much to inform his charitable care DNA. The thing most notably absent was a sense of value for the work being done. They’d bring their kids in one year and the child would have eight caries. The next year another six, often in the same place. The following year another 12 or 13. Trying to make sense of the staggering numbers, Verharen realized two things: until they could get a handle on the adults’ oral health, they would continue to chase problems in their children, and people simply didn’t value the services they received as part of government entitlement programs like DSHS and Medicaid. Not everyone, of course, but it was pervasive enough that he began to try and think of some way to deliver excellent health care to those without access to dentistry, but not just give it away. He clarifies, saying “I don’t believe there is a difference between the DSHS population and the population in private practice, but I do believe that the way that DSHS is set up promotes bad health, because it pays for it. There is no buy-in. At Service with a Smile, we charge them — in community service hours, so we’re not getting anything out of it financially, but we end up with great patients, and we know that the work that we do on them gets multiplied out in the community.” Whether or not that happens is hard to say — Verharen is eager to poll participants (patients and dentists alike) to track their long-term success in the community, but that’s a ways off. Ask anyone who’s ever toiled in a non-profit and you’ll find big dreams and miniscule resources.

The bones of the program
    All patients must first attend a rapid-fire orientation held about every three months at the Norm Dicks Government Center in Bremerton. It’s there that Verharen recently spoke to 20 people hoping to find a resource for free dental care. That’s about half his usual crowd, but Verharen admits he forgot to place an ad in the local paper announcing the event. It’s an understandable oversight — Service with a Smile continues to grow and administrative volunteers are hard to find and train. For now, Verharen tries to wear many hats within the organization and without — he’s running a successful practice in Bremerton, and he and Juli are busy raising three lively children — Dane, 6; Conner, 5, and Genoa 18 months...and in his “spare” time he’s the lead person for the program, something he’d eventually like to relinquish. On the night I sat through his spiel he was working at a fever pitch, distilling the promising program into sound bites cogent enough to get people on board: it’s a work for services program, there are clear expectations of each participant, it’s a traditional pay-as-you-go plan (only you pay with volunteer work), they don’t do extensive work like crowns, bridges and implants (“We end up doing a lot of work, but we don’t have any money for lab fees, so that’s where we get stuck. I would love to do everything,” says Verharen), and there are penalties for missed appointments. He explained the pace afterwards, saying. “We typically lose a third of the people as soon as they find out we don’t do crowns or dentures, and another few go when they find out they’ll have to do more than just sit back in a chair.”
    On that night, no one left before he’d hustled through the ten-minute Powerpoint presentation, and a good number stayed behind for clarification and questions at the end. To folks used to DSHS, Service with a Smile has some new hoops: they must first volunteer 13 hours before they can be seen by a participating dentist. By requiring preliminary volunteer work for the first appointment, Verharen knows this program can’t possibly help patients with emergent care needs, but that was never its intent. Service with a Smile won’t work for everyone, but it will work for a population intent on bettering itself. Although he’s still looking into how they can offer crowns and bridges (there’s no getting around the expense of lab work, but he’s working on a solution now), he always has envisioned the program as stop-gap measure — a way to help people get through until they can get a job and either have insurance or make enough to pay for dentistry.
    The program sets the value of each hour volunteered at $15 each — meaning the consultation, cleaning, x-rays and treatment plan that happen in the initial office visit “cost” the patient about $195 — well within industry standards. Then, they must log hours as they go, completing volunteer time before their dentist will perform work. It’s easy to see why after five years and some 3,000 people sitting in on orientation meetings, just some 300 or so have completed enough volunteer hours to qualify for the initial appointment, and somewhere between 50 and 75 have completed their treatment plans. But consider this: no other program in the country utilizes a model that requires participants to value the work being done enough to do work themselves. No other program encourages participation to help others in order to help yourself. Truth is, Verharen and others see entitlement programs as part of the problem, not the solution to access.
    Ask around, and you’ll find wide-spread praise for everyone from Verharen and his small board — who together are running this fresh approach to volunteerism — to the other dentists donating their skills and time, but most importantly, to the patients themselves. They are universally credited with being more motivated and dedicated to their health and well being by dentists like Sally Hewitt, Mike Huey and Vicky LeClair. And, Verharen will tell you about the transformational qualities of the program, how “Quite often, when people realize their work is valuable it often gets them out of that cycle of just standing in line waiting for a handout. It is really wonderful to watch.”
    Nina Edwards is just such a person — With no insurance and a mouthful of need, she didn’t know where to turn. Then one day her daughter told her about Service with a Smile, and Nina called in. Her treatment plan was aggressive and complex, and working it off took a year, but she did it. What she found so gratifying about the program was that she discovered that she could be valuable to others — in her case, at Abraham’s House, where she continues to volunteer even though she has completed all of her dental work. For Nina, what was most compelling was the realization that she was capable of changing her life with the simple act of volunteering.
    LeClair is new to the SWS program, but she echoes what Verharen says about value “Not everyone, but a lot of people on state assistance have a very ho-hum attitude, as if to ask ‘what can you do for me?’ It can get frustrating and very disappointing. I’ve only seen a couple of patients through Verharen’s program, and they’re still volunteering in order to complete her treatment plan, but I’d say it’s been a very positive experience. The patients are working to receive the treatment, they come to their appointments and they thank us. I think Tim did an excellent job at thinking this through and organizing it.” She continues, saying “I like the idea that they’re dependable — once they commit to it they are responsible about their appointments, whereas oftentimes with assistance patients they no-show and you never get a phone call or an apology for missing an appointment.”   
    Like LeClair, doctors and non-profits alike extoll the virtues of the program, and more importantly, the participants. Tina Mongrer of Abraham’s House, a faith-based organization in Bremerton, utilizes volunteers from SWS and calls them “some of the best volunteers we’ve ever had, in fact, some have stayed on and continued volunteering and one became a staff person.” And Lonny Folger, chief operating officer of the Communitas Group agrees, saying, “We’ve found the level of commitment among SWS volunteers to be very good because they’re dedicated to completing their dental work.”

What’s next?
    For now, Verharen sees the program as almost too big, saying “We’re at the point where we need someone to help coordinate our efforts. We’re large enough to require some sort of assistance, but not enough to qualify for state money.” He and board member Mike Huey are floating the idea of a Dental Navigator to help oversee the logistics of the program, to eventually take it beyond their community, expanding into regional and national scale formats. It’s an ambitious plan, and they’re still working to iron out the kinks of the local version, but they’re already getting inquiries from other local component societies interested in hosting similar programs in their communities. With grassroots support like that, it won’t be long before Verharen’s vision see’s greater scope in the region, and eventually, the country.

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