Florida Department of Health in Broward County
Broward Dental Seals: Sealing & Educating Little Smiles
Tooth decay is the most common chronic childhood disease and is almost entirely preventable, yet dental care continues to be the largest unmet health need of children in the United States. Broward County is a densely-populated area with more than 271,000 children and teenagers attending the 6th largest public school system in the nation, and a school-based sealant program is a highly-effective approach to improving dental access to such a large number of children in the community. The dental hygienists of the School-Based Sealant program that is administered through the Florida Department of Health in Broward County (DOH-Broward) provide dental cleanings, sealants, fluoride varnish treatments, and oral health education to students attending Pre-Kindergarten to 7th grade in 138 Title I elementary and middle schools throughout Broward County. Through October 2017, over 36,000 underserved children have received preventive dental services in a classroom setting that they otherwise would not have accessed. During that time frame, more than 95,000 permanent molars have been protected from tooth decay, making a difference in each child's oral health and overall quality of life. Website: http://broward.floridahealth.gov/programs-and-services/clinical-and-nutrition-services/dental-services/dental-sealants/index.html
Tooth decay is the most common chronic childhood disease and is almost entirely preventable, yet dental care continues to be the largest unmet health need of children in the United States. This condition is especially prevalent in low-income families. In 2013, almost 50% of the children who were enrolled in a Medicaid plan did not receive any dental care. DOH-Broward, with the support of Florida's State Surgeon General, endorses the implementation and expansion of school-based dental sealant programs to provide preventive dental services to underserved youth in local communities.
Broward County is a densely-populated area with more than 271,000 children and teenagers attending the 6th largest public school system in the nation, and a school-based sealant program is a highly-effective approach to improving dental access to such a large number of children in the community. The program's target population is students who attend Pre-Kindergarten through 7th grade at Title I elementary and middle schools throughout the county, which amounted to 96,854 students as of the enrollment count that took place on September 25, 2017. The classification of Title I indicates that the school population consists of 50% or more children who qualify for free or reduced-fee lunch, and likewise many of the children who participate in the program belong to families that have difficulties affording dental care. Through October 2017, a total of 36,679 distinct children have received preventive dental services during school hours since the inception of DOH-Broward's School-Based Sealant Program in March 2016. This amounted to approximately 38% of the target population. Many have utilized these services during each school year that the program was available to them, and have also begun fulfilling any required restorative dental care through referrals to DOH-Broward's pediatric dental clinics.
Each member of the program's staff was hired specifically to contribute to this innovative program, and the roles of the staff are modeled around the needs of both the clients and the program itself. By employing 16 licensed dental hygienists as the program's dental practitioners, it is achievable to visit each of Broward County's 138 Title I public elementary and middle schools over the course of one school year. These dental professionals provide children with preventive dental services that include sealants, fluoride treatments, cleanings, assessments, and education to children who would otherwise not receive any dental care.
Each hygienist has a highly productive schedule of an average of 16 clients in a classroom setting throughout the available school hours each day. Before the hygienists arrive at a school, screeners have reviewed consent forms for complete medical histories and parental signatures, and have organized them by class so the hygienists can quickly and easily locate the participating students. The portable dental equipment is moved between schools and set up in advance of the hygienists' visit, allowing them to begin seeing students promptly after arrival. Autoclaves are utilized in each school for convenient on-site sterilization of instruments, and any needed supplies are delivered to the hygienists by the program's drivers. Together, all of these aspects provide ample time for such a large population to be seen each school year.
DOH-Broward's School-Based Sealant program was modeled after similar sealant programs, but was implemented on a much larger scale than those of other county health departments and non-profit agencies. School-based sealant programs are slowly becoming more widespread as states are expanding their efforts to meet the oral health objectives of Healthy People 2020, which include reducing the proportion of children who have tooth decay and increasing the rate of children who have received dental sealants. However, many states are not meeting these national objectives. By taking the steps to increase access to care for children in low-income families, DOH-Broward is supporting not only the Healthy People 2020 objectives but also the state of Florida's goal of being the healthiest state in the nation.
DOH-Broward and the Broward County School Board have a scope of work in place that allows all students in Title I schools to receive preventive dental services in a classroom setting. All students who submit a consent form that has been completed by their parent or legal guardian, and who have received medical clearance by a DOH-Broward physician or dentist, are eligible to receive the available preventive dental services. The consent forms include information on the program and on the benefits of dental sealants, and every student receives one during the first week of each school year. Program staff have attended parent events at schools and community health fairs to promote the benefits of dental sealants to local parents, which allowed any questions to be answered and contributed to an increase in the number of families who participated in the program.
The goal of DOH-Broward's School-Based Sealant program is to provide preventive dental services to the underserved youth of Broward County, many of whom do not receive dental care on a regular basis or at all. In doing so, the program is contributing to the oral health objectives of Healthy People 2020, which include reducing the proportion of children who have tooth decay and increasing the rate of children who have received dental sealants. The role of the each of the dental hygienists is to provide preventive dental services to an average of at least 16 children per day. Through October 2017, more than 8100 students have been seen in just 36 school days, which amounted to an average of 225 clients per day. This achievement improves numerous children's oral health and increases their overall quality of life.
DOH-Broward's School-Based Sealant program began providing dental services to children attending Kindergarten through 3rd grade in Broward County's Title I public elementary schools in March 2016, with ample planning, community collaboration, and staff training taking place beforehand. The program was implemented through a grant of $1,271,228 from the Agency for Health Care Administration. It allowed for the purchase of portable dental equipment, instruments, patient forms, and all disposable supplies needed for the placing of dental sealants. In the 2015-2016 school year, 9,485 distinct children received dental services. Participation in the program increased to 27,575 distinct children attending Kindergarten through 7th grades during the 2016-2017 school year.
The 2017-2018 school year has only recently begun, but many avenues have been explored to supplement primary funding. United Way has granted $89,248.00 to utilize for the expansion of the program to five schools that have been newly classified as Title I, as well as to four alternative learning centers that educate at-risk teenagers. A Maternal and Child Health grant of $126,411.00 was applied to fund the provision of dental services to students who are not insured. A grant of $64,362.80 from Florida Health County Health Systems allowed for extra sets of portable equipment and autoclaves to be purchased in order to have them set up in preparation for the hygienists' arrival to each school. Additionally, a donation of sealant material and fluoride varnish from Oral Health America will supply preventive services for approximately 5000 children.
Demographics vary throughout Broward County's expansive range of 1323 square miles, and the operation of each individual school reflects the specific needs of its community's students and their families. An issue that was shared by the majority of the school administrators, faculty, and parents, regardless of location and demographics, was the lack of knowledge regarding the importance of dental care and how tooth decay can affect numerous aspects of a child's life. Children can easily avoid difficulties with eating, speaking, sleeping, socializing, self-esteem, and learning through the prevention of dental pain and infection. Children who are experiencing pain, infection, and other dental-related emergencies miss school days three times more often than those without tooth decay. This event results in lower educational outcomes throughout childhood, and the effects continue into adulthood.
To instill dental care as a value point, the management of DOH-Broward's School-Based Sealant program meets with school principals, assistant principals, guidance counselors, social workers, office managers, and teachers to discuss the benefits of dental sealants and other preventive dental services, and works with them to share this information with their local community to increase participation in the program. DOH-Broward school health nurses have also been able to promote the program internally while visiting the schools. Each school that is visited receives a summary of the quantity of its students seen by the dental hygienists, sealants placed, and dental emergencies identified. The school administration and faculty are acknowledged for their participation in increasing access to dental care for low-income children who do not receive dental services on a regular basis.
Once the children are seen by the dental hygienists, their medical histories and services rendered are entered into DOH-Broward's Health Management System and it is noted if they are not enrolled in Medicaid. Any child without Medicaid coverage who received services from the School-Based Sealant program is referred to the Florida KidCare insurance program. KidCare representatives contact the parents of uninsured children to determine if they would like to apply for health insurance and advises them on plans that include dental coverage. The School-Based Sealant program is then notified when any of its clients enroll in a KidCare coverage plan.
The School-Based Sealant program also works closely with DOH-Broward's pediatric dental clinics to increase the number of children who have a dental home. Every child that participates in the program receives an informational card regarding the dental clinics, including the ages that can be seen and the phone number the parents can call when they would like to make an appointment for their child. This phone number is also included on a letter that is sent home to the parents, which describes the services rendered and necessary referrals. In addition, the parents of children who are identified as experiencing a dental emergency, including pain, swelling, or abscesses, are contacted by phone immediately and are provided with the phone number for the DOH-Broward dental clinic appointment line. These parents are also contacted by DOH-Broward's call center until the parent has confirmed that their child has received dental treatment.
DOH-Broward supports the oral health goals of Healthy People 2020, and its School-Based Sealant program is contributing to these objectives on a large scale. The objective of reducing of the proportion of children who have tooth decay is accomplished by placing sealants on over 95,000 permanent teeth, providing fluoride varnish treatments, and educating children on oral health. The rate of children who have received dental sealants continues to increase each year as the program expands, and processes are evaluated to further increase the School-Based Sealant program's impact on public health. To enhance the effect the program has on the youth of the community, the hygienists each have a goal of providing dental services to an average of 16 children per school day.
DOH-Broward utilizes Active Strategy, an analytic program that extracts data from the department's Health Management System to measure the achievement of program goals. All services rendered are recorded on treatment forms, which the hygienists complete for each child seen. These forms are delivered to the program's data entry staff and are entered into HMS.
At the School-Based Sealant program's inception in March 2016, one of the objectives was for each dental hygienist to provide preventive dental services to an average of 13 children per school day. This rate is measured by dividing the total students seen per month by the number of hygienists who visited schools and again by the number of days they provided services during that particular month. In September 2016, the average amounted to 9.76 daily, while in October 2016 the average rose to 11.86 per day.
The total number of days in the school calendar, as well as each individual school's daily hours, limits the amount of time that can be scheduled to visit all of the Title I elementary and middle schools throughout Broward County. To allow for more time for the hygienists to be able to provide dental services in the school setting, daily production was analyzed and acted upon. Suggestions were taken from supervisors and directors, as well as from the hygienists who had been directly experiencing the daily school schedules, to discuss in detail methods of increasing the number of clients seen per day.
It was determined that school events and other needs of the school administration periodically slow production, but these cannot always be avoided and so the hygienists are flexible in working around these obstacles. However, a daily occurrence was the hygienists finishing their production before the school day concluded in order to perform other tasks. This stoppage occurred so they could travel to DOH-Broward each afternoon in order to sterilize instruments and deliver their daily paperwork. It also occurred every few days when they completed all treatment at a school and were required to pack their dental equipment into a van and set it up again at their next scheduled school.
Since the 2017-2018 school year began, the program's drivers have been setting up the dental equipment in advance of the hygienists' arrival to each school, and have also been utilized to transport the daily paperwork from the schools to DOH-Broward. The hygienists are able to sterilize their instruments in autoclaves that are brought to each school along with the rest of the dental equipment. These changes allow the hygienists to continue providing dental services to students throughout the entire school day. In comparison to the prior school year, in September 2017 the daily average was 14.56 clients per hygienist, while in October 2017 the rate was 15.06. The goal has now been raised to 16 clients per hygienist each day, which will allow for even more underserved children to participate in DOH-Broward's School-Based Sealant program in the duration of each school year.
DOH-Broward continually monitors its School-Based Sealant program to utilize opportunities for improvement and expansion that will sustain the program so it can continue to provide preventive dental services to the underserved youth of Broward County. Its primary source of funding is through Medicaid reimbursement of the dental services rendered, but grants and donations are also considered and applied for as a supplement to primary funding. Additionally, community involvement is fundamental in order to continue to provide these services to existing clients each school year throughout their childhood, as well as to expand the program to accommodate additional underserved children who could benefit from accessing preventative dental care that they may otherwise not receive.
Broward County consists of a very transient population, and DOH-Broward's School-Based Sealant program will be able to provide dental services to children who have migrated from other areas. Many families also move across the school boundaries throughout Broward County, and the children who previously attended charter, private, or non-Tile I public schools are able to be seen through DOH-Broward's School-Based Sealant program if their new school is classified as Title I. Additionally, over 22,000 births occur annually to residents of Broward County, many of which have a high probability of entering into a Kindergarten class of one of Broward County's 107 Title I elementary schools in the coming years with the potential of becoming clients of DOH-Broward's School-Based Sealant program.
DOH-Broward's School-Based Sealant program has recently been able to reduce costs by arranging for the dental hygienists to primarily provide dental services and perform dental-related tasks, such as sterilization. In the past, they used time that could have been spent on client treatment to move and set up the portable dental equipment themselves, and occasionally screened consent forms. By employing drivers and screeners to provide important yet time-consuming clerical and physical duties at a lower hourly rate than that which the hygienists receive, expenses are reduced and the amount of time available for treatment of clients has drastically increased, allowing for a larger number of children to be able to receive preventive dental services throughout the school year.
To contribute to the sustainability of the program, targets that are related to production and Medicaid billing have been established. A high provision of dental sealants to the program's clients increases the amount that can be reimbursed, and so the target is to seal 65% of the clients. The average rate of clients sealed in October 2017 was 64.22%. Another target is that at least 50% of the clients are billed through Medicaid. Approximately 63% of the clients seen were able to be billed through their Medicaid coverage in October 2017. The year-to-date average reimbursement per billed client has a target of $74.75 and the actual average is $79.13.
The financial benefit that this program provides to the local community is immense when compared to the cost of providing the services. Through October 2017, DOH-Broward's School-Based Sealant program has saved taxpayers in Broward County approximately $24.5 million in dental fees by providing the preventive dental services of fluoride varnish applications and sealants, as well as for the prevention of restorations. Through its School-Based Sealant program, DOH-Broward places dental sealants at no cost to the clients. On average, sealants cost $44.12 per tooth when applied at a dental office. A total of 95,134 teeth were sealed, and therefore protected from decay, during the approximately 12-month timeframe that schools were in session from March 2016 through October 2017. Underserved families throughout the county saved approximately $4.2 million on dental sealants. The combination of sealants and fluoride treatments prevents nearly all incidences of tooth decay. During this time period, DOH-Broward also applied 46,747 fluoride varnish treatments. Fluoride varnish costs patients approximately $35 per treatment when applied at a dental office. The School-Based Sealant program saved families of low income nearly $1.6 million in fluoride applications. The average dental restoration (amalgam and resin-based composite fillings) costs $197.09 per tooth. Placing sealants on 95,134 teeth saved taxpayers in our community over $18.7 million in dental restorations through the prevention of tooth decay in the 1st and 2nd permanent molars alone, in addition to the other primary and permanent teeth that are protected by the fluoride varnish applications.
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