Referral and Follow-up
Many students treated in school-based dental sealant programs do not have a usual source of oral health care (dental home). School-based dental sealant programs can serve as stepping stones to the establishment of a dental home by linking students with oral health needs to the broader oral health care community. To accomplish this, programs need a plan for notifying parents about their child’s oral health needs and for helping parents find a dentist for their child, if they don’t already have one.
The first step is to identify and cultivate relationships with referral sources in the community. The state dental society, the state office of oral health, community and migrant health centers, public health clinics, hospital dental programs, dental schools, comprehensive portable dental programs, and dentists in private practice may be able to aid in the establishment of a dental home. Program administrators may wish to prepare a list of dental-home-referral sources by neighborhood. The list should indicate which dentists and safety net dental clinics (e.g., community health centers, hospitals) accept Medicaid or the CHIP. If dentists or safety net dental clinics do not accept Medicaid or CHIP but are willing to treat students from families with low incomes, the list should clearly state the terms of payment.
It is also wise to develop a list of dentists or safety net dental clinics willing to provide emergency care to students with urgent problems (e.g., pain, swelling). These dentists or safety net dental clinics will not necessarily become the student’s dental home; rather they treat urgent problems until a dental home can be established.
It is important to contact all dentists or safety net dental clinics to confirm that they accept Medicaid or CHIP and provide treatment to students who are participating in the school-based dental sealant program. In addition, it is a good idea to provide dentists and safety net dental clinics with a letter of agreement. The letter of agreement protects dentists or safety net dental clinics from expectations that they will provide services beyond those agreed upon and safeguard against undue disruption to dentists or clinics.
Each student that participated in the school-based dental sealant program should bring a letter home informing their parents of how many dental sealants were placed, whether any obvious oral disease was identified, and whether the student needs treatment urgently (within 48 hours) or non-urgently (within 6 weeks). The letter should also emphasize the importance of regular dental visits and should provide a phone number that parents can call if they have questions.
Staff need to do their best to ensure that students receive necessary treatment. For students who have been referred for treatment, program administrators may choose to send the student’s parents a follow-up letter or to contact them by phone. For students with pain or swelling, extra efforts should be made to ensure that appropriate care is provided.
If a school nurse is available, program staff can provide the nurse with a list of students with oral health needs. The nurse is likely to be in contact with parents about students’ health problems. In addition, students experiencing oral pain at school will be sent to the nurse’s office. It can be helpful for school-based dental sealant program administrators to provide the school nurse with a list of dentists or safety net dental clinics that are willing to provide emergency care, as well as a list of dental-home-referral sources, as mentioned previously.
School-based dental sealant program administrators should consider developing a system to track the effectiveness of the program’s referral component. Most school-based dental sealant programs re-assess as many students as possible 1 year after sealant application to determine whether the sealants have been retained. At that time, the status of oral health needs can be monitored, and the effectiveness of follow-up methods can be determined.
Ensuring that students receive needed oral health care is challenging. A panel of experts was convened on May 11–12, 2006, in Washington, DC, to discuss strategies to overcoming barriers to accessing oral health care. The report from that panel, titled “Improving the Oral Health of School-Aged Children: Strengthening School-Based Dental Sealant Program Linkages with Medicaid/SCHIP and Dental Homes,” provides useful information. Following is a list of the types of strategies discussed at the meeting:
Case management is a process whereby families receive help with finding and using oral health care services, including establishing dental homes. The process, overseen by a case manager, addresses any need or circumstance that may prevent students from receiving needed oral health services. Case managers must understand students’ oral health care needs and must act to ensure that these needs are met. Activities undertaken by case managers include
- Engaging parents in obtaining needed oral health care for their children
- Enrolling students and their families in insurance plans (e.g., Medicaid, CHIP)
- Helping families use their insurance coverage (e.g., filling out forms, following insurance-coverage policies)
- Identifying dentists in the community who will accept students enrolled in Medicaid or CHIP
- Setting up appointments
- Educating students and their families on how to be good patients (e.g., arriving on time for appointments, appropriate waiting room behavior)
- Arranging transportation
- Obtaining translation services
- Following up to ensure that needed oral health care was received
It is important to establish approaches for providing services based on the needs of the community in which the school-based dental sealant program operates. Case managers can include health and social service professionals (e.g., dental hygienists, dental assistants, school nurses, social workers), administrative staff, or volunteers. Case-management services and case managers’ level of effort vary depending on the geographic and sociodemographic needs of the community as well as each individual case manager’s level of expertise.
Fixed-Site and Portable Clinics in School-Based Oral Health Programs
School-based oral health programs can efficiently provide students with access to comprehensive services (e.g., oral prophylaxes, topical fluoride treatments, dental sealants, restorative care, education). Such services can be offered through fixed-site clinics, portable clinics, or a combination of the two.
Fixed-site clinics tend to offer comprehensive services to students, whereas portable clinics tend to provide preventive and basic diagnostic and restorative care (e.g., bitewing X-rays, restorations). The combination of portable clinics to conduct examinations and provide preventive care and fixed-site clinics to provide advanced treatment can serve as an effective alternate dental home for students who do not have another dental home.
Mobile Dental Vans
Properly outfitted, mobile dental vans can provide comprehensive and ongoing oral health care to students living in geographic areas where fixed dental clinics may not be available (e.g., rural communities, inner cities). It is important for mobile dental van programs to identify a geographic area in which the program can meet the population’s oral health care needs (e.g., provide routine preventive procedures, deliver restorative oral health care). Programs that serve overly large geographic areas (e.g., entire states, multiple counties) are generally not able to effectively serve as dental homes because there are times when the van is not accessible to those in need of care.
Safety Net Dental Clinics
Creating links with local safety net dental clinics is another approach for establishing dental homes for students participating in school-based dental sealant programs. Safety-net dental clinics can provide comprehensive and ongoing oral health care to children from families with low incomes and to other underserved populations.
Safety net dental clinics are usually staffed by community-based oral health professionals and are generally located in areas that serve populations that face various access barriers, often including limited ability to pay for care. These clinics are frequently located in community settings such as public schools, community health centers, Indian Health Service clinics, public health departments, dental schools, hospitals, and private not-for-profit service agencies (e.g., social service agencies).
Other strategies include
- Advocating, in collaboration with community coalitions, for competitive or market-based Medicaid and CHIP reimbursement rates and policies that allow for easier administration of the program.
- Helping families complete applications for Medicaid or CHIP, so that children have dental insurance.
- Encouraging and mobilizing parents to take their child to the dentist; understanding the barriers faced by parents whose children are treated in school-based dental sealant programs (e.g., transportation, keeping appointments).
- Addressing the communication and information needs of families from various cultural backgrounds who speak a primary language other than English.
- Recruiting new dentists to participate in state Medicaid, Medicaid-managed-care dental programs, and CHIP, and encouraging those already participating to treat children.
- Compiling lists of referral sources by neighborhood that have agreed to provide treatment to students participating in the school-based dental sealant program.
- Partnering or collaborating with pediatric physicians or departments who have shown a disposition for recognizing the importance of oral health for overall health.
School-based dental sealant programs that wish to offer Medicaid and CHIP outreach activities may be able to obtain additional funding through the Medicaid administrative match process. The Medicaid administrative match can provide additional funding for Medicaid outreach activities that may include care coordination and referrals to other health professionals (medical or dental), provide eligibility applications to parents and children, and assist families in the Medicaid and CHIP application process.