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Practice Management
Dental Care Access for Hispanics in Minnesota
A culturally sensitive medical and dental model
Christopher Okunseri, B.D.S., M.Sc., F.F.D., R.C.S.I.,
*Karl Self, D.D.S., M.B.A.,
** David O. Born, Ph.D.,Ê
and Marlene Pineda, D.D.S.ÊÊ
Introduction
In May 2000, the first-ever Surgeon General's report on oral health was released to the nation. It alerted all Americans about an overall improvement in oral health, emphasized the full meaning of oral health, the link between oral health and systemic health and the importance of oral health to general health and well being.1
The report also catalogs information about racial/ethnic minorities in the United States as being the demographic groups most disadvantaged by oral health disparities and access to care.1 It calls for action to address oral health disparities.1 The Federal Healthy People 2010 program, with its state- and community-level support organizations, also identified oral health disparities and set specific goals for their reduction by the year 2010.1
MinnesotaÍs racial/ethnic minority population grew from 6.3 percent in 1990 to 11.8 percent in 2000.2 During that period, the number of Minnesotans who identified themselves as Hispanic grew from 54,000 to 143,382, an increase of 166 percent,2,3 ranking them third among racial/ethnic groups in the state. Approximately 50 percent of Hispanics reside in the Twin Cities Metropolitan area.2,3
In general, the racial/ethnic minority populations in Minnesota are younger on average.2 This age structure, combined with continuous in-migration and higher natural rates of increase, will continue to contribute to the growth of racial and ethnic diversity in Minnesota.2 More than 22 percent of Minneapolis public school students come from homes where English is spoken as a second language, Spanish being one of the most prevalent.4
Hispanic children are at greater risk of developing dental disease than white and African American children.1 In a study conducted in the Bronx, New York, Hispanic children had a higher dental caries experi-ence (DMFS = 1.71) compared to African American children (DMFS = 1.14).5 Another study also found that white children from low-
income families were 1.5 times more likely to have seen a dentist than African American, American Indian and Hispanic children.6 White and Asian children were 60 percent more likely to have received dental services than Hispanic children.6
Hispanic and other minority populations experience some of the greatest difficulty in accessing dental care. This situation gets worse when they are either unemployed or participants in the Minnesota Health Care Program (MHCP). Studies conducted in Minnesota in mid-1990 showed that 70 percent of Minnesotans with commercial insurance, compared to 30 percent of MHCP recipients, had visited the dentist in the previous year.7 Reports have enumerated several barriers, including poor reimbursement, lack of transport, inadequate workforce and language and cultural factors, as responsible for the poor access to care by MHCP patients.8 Access to dental care in most inner city communities in Minnesota remains a complex challenge for persons covered under MHCP.9
Stakeholders have proposed multiple strategies to help alleviate the problem, some of which include increasing reimbursement, expanding functions for dental auxiliaries, expanding a loan forgiveness program for graduates who practice in designated dental health professional shortage areas and modifying eligibility requirements for foreign trained dentists wishing to take the Central Regional Dental Testing (CRDT) examination.7
The development of a culturally sensitive practice model is seen by some stakeholders as another potential avenue to reach out to those most affected by oral health disparities and access to dental care. The health care industry and dental regulatory bodies are also developing culturally sensitive materials designed to improve providersÍ awareness and ability to meet the needs of their racially and ethnically diverse populations.
Physicians and other allied health care professionals now run practices strictly designed to meet the cultural, social, perceived and normative needs of the populations they serve. This type of practice model involves the use of bilingual staff within a culturally sensitive environment. These practices help to reduce some of the cultural barriers to providing care such as eliminating the language barrier and creating a nurturing environment for patients. Providers in these practices acquire their cultural knowledge either through training or by virtue of being from a racial/ethnic minority group. This helps them provide culturally competent care.
We acknowledge that some private offices already employ bilingual staff, but this is only one aspect of the concept, especially when compared to an office where all members of the staff are not only bilingual but of the same cultural background as the patients they serve. Public/private partnership practices aimed at developing a culturally sensitive practice will require information on racial/ethnic minority workforce profile. This information is essential for the success of these types of partnerships.
In Minnesota, there is a lack of data on racial/ethnic minority participation in the workforce. Collaborative efforts can be instituted among organizations, dental professionals and the University of Minnesota in recruiting and retaining minority students interested in dentistry and in data collection of racial/ethnic minority workforce members. In medicine, data collection on these issues is underway and continues to sustain that professionÍs ability to create culturally sensitive practices to meet the needs of their communities.
The medical profession has also acknowledged the benefits of a culturally sensitive practice model by providing care in culturally sensitive settings. This has helped to bridge
some of the medical health disparities within racial/ethnic minorities in Minnesota. This approach requires elements of partnership, integration and reorientation among all stakeholders to initiate scientific programs with culturally sensitive bases. The dental profession could also begin to work in that direction.
This paper seeks to describe a culturally sensitive medical and dental model developed to address access to dental care for Hispanic children and families in Minnesota. It uses racial/ethnic minority staff within a culturally sensitive environment to provide dental care for Hispanic children and families, irrespective of their type of insurance or immediate ability to pay for services. The project also includes a research component to collect oral health information, which is otherwise unavailable at state or city levels.
Medical/Dental Model
The project was initiated by the Community-University Health Care Center (CUHCC) following discussions with Centro, Hispanic community advocates and other stakeholders. The discussions identified key issues pertaining to the project such as funding, oral health needs, billing, scheduling, insurance, staffing, dental clinic space and days/hours of operation. The project was set up to serve the Hispanic community in Minnesota under the auspices of Centro „ a multifaceted social service agency described in greater detail later in this article. Centro provides family counseling, employment support, a food shelf and child care to the Hispanic community in Minnesota.
The Hispanic community advocates also enumerated some of the difficulties they experience in regard to oral health and lack of access to dental care. They suggested the use of bilingual dental personnel for the provision of dental care to help maintain the cultural tone set by Centro and to reduce language barriers. They also wanted the culturally rich and friendly medical facility environment of Centro de Salud to be utilized. This would help reduce multiple transportation costs and afford beneficiaries the opportunity to access medical, dental and social care all in one location. The approach was considered by patients as a one-stop shopping process for almost all their health and social service needs. The oral health project was seen by all stakeholders as essential in helping to reduce some of the difficulties encountered by Hispanic children and families in accessing dental care.
The project partners were:
´ Centro and Centro de Salud social services and medical team
´ Community-University Health Care Center (CUHCC)
´ Hispanic community advocates of Centro
´ University of Minnesota School of Dentistry
´ Apple Tree Dental
Centro and Centro de Salud
Centro de Salud is a medical facility located within the Centro facility in south Minneapolis. Its mission is to meet the medical needs of Hispanic children and families in the community. The medical clinic is the result of a collaborative effort between Centro, Planned Parenthood of Minnesota/South Dakota, ChildrenÍs Hospitals
and Clinics and Hennepin Faculty Associates.
The medical services offered include routine examinations, immunizations, well-child checks, breast and cervical cancer screening and pregnancy testing. The medical facility has culturally sensitive features which bring the feeling of home to patients and families, and almost all forms of medical insurance including Medicaid and MinnesotaCare are accepted. For those without insurance, there is a clinic fee based on ability to pay.
Centro sees approximately 3,000 patients per year, 40 percent of whom are children. Between 75 percent and 80 percent of the patients are low income and uninsured. The clinical staff is bilingual and sensitive to the cultural aspects of the Hispanic community.
Community-University Health Care Center (CUHCC)
CUHCC is a multidisciplinary community clinic also located in South Minneapolis. Its mission is to provide accessible, affordable, culturally acceptable health care to uninsured and underinsured individuals. CUHCC initiated this outreach project, funded in part by a grant from The Medtronic Foundation, to meet the unmet dental needs of low-income Hispanic families, especially those in south Minneapolis.
Anecdotally, reports from Centro de Salud clinicians and Hennepin County Medical Center pediatricians suggested that there were unmet dental needs among their Hispanic patients. The reasons given for this situation included the non-availability of dental providers, lack of insurance coverage or status as Minnesota Health Care Program (MHCP) recipients, language barriers and the absolute lack of a culturally sensitive environment like Centro de Salud. These reports were instrumental to the establishment of the project.
The School of Dentistry, University of Minnesota
The School of Dentistry, University of Minnesota (Division of Health Ecology) provided some of the manpower needed for both the clinical and research components of the project. A database was developed for collection of oral health information. The University of Minnesota Institutional Review Board approved use of the information for scientific research purposes. Analysis of this data will be used for documenting the oral health status of patients, for evaluating the project and for assessing cost effectiveness.
Apple Tree Dental
Apple Tree Dental is a non-profit organization that has a history of utilizing portable dental equipment to increase dental access for nursing home residents and those who have difficulties accessing fixed clinics. Apple Tree Dental was contracted by the project to provide the portable dental equipment and supplies, as well as a dental assistant to maintain the equipment, sterilize instruments and support the chairside team. Apple Tree transports, sets up and maintains the portable equipment for the clinic.
Program Operation
A flyer with news about the planned dental service was posted at Centro de Salud for all patients attending the site. Promotional activities were also undertaken at a health fair in South Minneapolis. The clinic itself was named ñClinica Dental Hispanaî and prospective patients were invited to make an appointment. The fliers also included information about health insurance coverge, types of dental services available and hours of operation.
The dental team members are native Spanish speakers drawn from the staff at CUHCC. Centro de Salud front desk staff handles scheduling of patients; CUHCC staff handles medical records and patient billings. Demand for services has been overwhelming, with patients from all over Minnesota requesting appointments. At present, there is a waiting period of three months due to the influx of patients calling for appointments. Analyses of the zip codes of patients show that many are coming from outside the south Minneapolis area. One strategy that has reduced the no-show rate in this project has been an effort on the part of the care provider to call patients 24-48 hours to reconfirm appointments.
Essentially this project involves a one-chair ñportableî dental clinic located within a medical clinic . It is open one day a week to provide preventive and restorative services to Hispanic children and families. Where extensive care, specialty care or major surgical dental care is required, patients are referred to either CUCHH or the School of Dentistry. The dental staff is also involved in providing oral health promotion and education seminars to Hispanic children in the facility. A research component in the project includes data collection of baseline oral health status, sociodemographic variables, insurance type and previous dental visits.
Preliminary data analyses showed that 75 percent of the patients are uninsured and pay fees for their services based on income and family size; another 21 percent are MHCP recipients. The authors are also interested in the workings of specific sociodemographic variables which may affect the utilization or non-utilization of dental services, levels of unmet dental needs, percentage of patients with dental visits in the preceding 12-month period and dental sealant utilization.
Figure 1 shows initial dental visits to the clinic for three-month intervals. The number of initial dental visits increased from July to December 2002, but from January to March 2003 there was a slight decrease in the number of new enrollees seen due to an increase in recall visits of previous enrollees. Figure 2 shows that many patients have not seen a dentist within the past two to three years (10 percent), and the vast majority have never been to the dentist (70 percent)
.
The impact and appropriateness of this approach to the delivery of dental care will be assessed at the end of the first year, using a self-administered questionnaire. Detailed reports on the oral health status of the population will also be published. The authors believe this project demonstrates a culturally sensitive medical and dental model which utilizes a cultural setting and the use of bilingual providers within a culturally sensitive environment to provide dental care and address the lack of adequate access to care.
References
1. US Department of Health and Human Services: Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Health, National Institute of Dental and Craniofacial Research, 2000.
2. www.mnplan.state.mn.us/demography/Census
2000.html: United States Census Bureau 2000, accessed Feb. 12, 2003.
3.www.clac.state.mn.us/pdfs/brief.pdf: The Hispanic/Latino Population in Minnesota 2000.
4. City of Minneapolis, State of the City 2001.
5.Okunseri C, Badner V, Kumar J, Cruz G. Dental caries prevalence and treatment need among racial/ethnic minority school children. NYSD J 2002;Oct.:20-23.
6.Minnesota Department of Revenue: Executive Information System (EIS) Claims Data 1999.
7.Minnesota Department of Human Services: Dental Access for Minnesota Health Care Program Beneficiaries Report, Jan. 2001.
8.Eklund SA, Pittman JL, Smith RC: Trends in dental care among insured Americans, 1980 to 1995. JADA 1997; Feb.:171-78.
9.Minnesota Department of Human Services: Dental Services Access Report, March 1999.
*Dr. Okunseri is Assistant Professor, Department of Preventive Sciences, Division of Health Ecology, University of Minnesota School of Dentistry, Minneapolis, MN 55455.
**Dr. Self is Executive Director, Community-University Health Care Center, Minneapolis, MN 55404.
***Dr. Born is Director, Division of Health Ecology, University of Minnesota School of Dentistry, Minneapolis, Minnesota 55455.
***Dr. Pineda is a general dentist at the Community-University Health Care Center, Minneapolis, Minnesota 55404.
Copyright 2003. Minnesota Dental Association.
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