Increased Access to Dental Health Care for Underserved Populations Through Community Partnerships

State: FL Type: Model Practice Year: 2014

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The health department has partnered with the College of Central Florida since March 2004, with an overarching goal of increasing access to dental care for underserved populations in Marion County. The college has an accredited Dental Assisting Program and the health department is one of 67 counties comprising the integrated Florida Department of Health. The partnership created the Hampton Dental Clinic, located in the poorest zip code of the county. The clinic includes eight dental and two pre-clinic operatories. The Hampton campus was built at a cost of $1,959,000. Equipment, instruments and supplies were purchased by the health department through a grant of $150,000 from the State of Florida in 2003. In-kind donations from the Marion County Dental Association contributed to the college Dental Assisting program.

Despite the challenges, the partnership has succeeded. The three objectives were met. The number of unduplicated child patients has increased steadily from 436 in 2003-2004 to 1606 in 2011-2012. The standardized dental assisting training is being provided, along with provision of dental care for low income dental assisting students. The students have exceeded a 90% pass rate for the Dental Assisting National Board, with individual scores well above the national average. Sustainability has also been achieved. Both organizations have lower overhead costs and the clinic has been able to remain in operation even with three of eleven positions cut in 2012, and the advent of managed care.

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Marion County Health Department
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Increased Access to Dental Health Care for Underserved Populations Through Community Partnerships
Marion County is located in North Central Florida, and is Florida’s fifth-largest, spanning 1,652 square miles. The county has a total population of 331,298.The target population of the Marion County Health Department dental practice is 34,306 Medicaid eligible public school children. The children are 58.98% Caucasian, 19.46% African American, 14.58% Hispanic, 4.71% Multicultural, 1.72% Asian, and 0.55% Indian. The challenge is huge. According to the non-advocacy Pew Research Center report of May 24, 2011, "Dental care is the greatest unmet need among children. More than 16 million U.S. children go without even basic dental care each year." And, the May 2011 PEW report card, The State of Children’s Health: Making Coverage Matter, gave Florida an "F" grade for its failure to meet the policies necessary to improve oral health. The health department has partnered with the College of Central Florida since March 2004, with an overarching goal of increasing access to dental care for underserved populations in Marion County. The college has an accredited Dental Assisting Program and the health department is one of 67 counties comprising the integrated Florida Department of Health. The partnership created the Hampton Dental Clinic, located in the poorest zip code of the county. The clinic includes eight dental and two pre-clinic operatories. The Hampton campus was built at a cost of $1,959,000. Equipment, instruments and supplies were purchased by the health department through a grant of $150,000 from the State of Florida in 2003. In-kind donations from the Marion County Dental Association contributed to the college Dental Assisting program. To assess progress in attaining the overarching goal, three objectives were defined: Increased access to dental care for county residents at or below 125% Federal Poverty Level (FPL) Ability to offer standardized training in the clinical setting for Dental Assisting Program students, while providing dental care for those students in the program at or below 125% FPL How sustainable is the dental practice after experiencing multiple budget cuts. Despite the challenge, the partnership has succeeded. The three objectives have been met. The number of unduplicated child patients has increased steadily from 436 in 2003-2004 to 1606 in 2011-2012. The standardized dental assisting training is being provided, along with provision of dental care for low income dental assisting students. The students have exceeded a 90% pass rate for the Dental Assisting National Board, with individual scores well above the national average. Sustainability has also been achieved. Both organizations have lower overhead costs and the clinic has been able to remain in operation even with three of eleven positions cut in 2012, and the advent of managed care. The Florida Department of Health has also included a mandate in its agency strategic plan for each LHD to work to forge partnerships, including oral health care provider roles in the community; and to identify and implement strategies to improve access to health care services. Through the partnership, oral health education is being promoted in the clinical setting and in local schools, daycares, and instructional clinics to groups. School fluoride programs and oral health presentations have been instituted; and 2011 saw the inaugural National Dental Health Month poster contest. The impact of the partnership is extremely evident in the community, creating new enthusiasm for an existing community health coalition. We believe four factors led to the success of the practice, and can be emulated with relative ease by other health departments. These factors are: a shared focus on common goals while addressing individual organizational needs; sensitivity to each partner’s strengths and challenges; a continuing emphasis on timely, effective communication; and the concurrent actions of the health department to obtain national public health accreditation. The accreditation standards have served as a valuable guideline for development of, and sustaining a community partnership.
Marion County is located in North Central Florida, encompassing more than 1,652 square miles making it one of Florida’s larger counties. The county has a population of 331,298 with 41,173 children enrolled in public schools (2012 Census). The target population of the Marion County Health Department dental practice is 34,306 Medicaid eligible children. The children are 58.98% Caucasian, 19.46% African American, 14.58% Hispanic, 4.71% Multicultural, 1.72% Asian, and 0.55% Indian. Limited access to health care services contributes to poor public health outcomes and high health care costs in the county. This is due to numerous factors, including the low number of Medicaid dental providers, a large number of Medicaid Eligible children, transportation difficulties, lack of fluoridated water, high incidence of poverty, low level of parent education, and homelessness (2,700 children in Marion County public schools are legally homeless). While there are over a hundred dentists in the county, most of them treat adults; and in particular the older more affluent population. There are only seven providers that serve children under Medicaid. Of the seven, five are private practices which mainly treat children with private insurance. In addition, there is only one dentist that accepts public insurance for children slightly above the Medicaid eligibility threshold. There are 34,306 Medicaid Eligible children in the county. According to the Agency for Health Care Administration (AHCA) there should be a ratio of one dentist per 1500 patients. Using that criterion, there should be 23 dentists in Marion County that treat only children on Medicaid. Access to dental care can keep children out of emergency rooms and in school where they can learn. Oral health care and health education is needed to help change the patterns of behavior which lead to dental decay and gum disease. According to the non-advocacy Pew Research Center report of May 24, 2011, "Dental care is the greatest unmet need among children. More than 16 million U.S. children go without even basic dental care each year." However, the May 2011 PEW report card, The State of Children’s Health: Making Coverage Matter, gave Florida an "F" grade for its failure to improve oral health. In an effort to remedy this deficit, John H. Armstrong, MD, FACS, Surgeon General and Secretary of Health for the State of Florida has directed the 67 county health departments comprising the integrated Florida Department of Health to coordinate and work in conjunction with their local public and private sector public health partners to identify, evaluate, prioritize, and address community health issues, including oral health care. At the local level, the health department has partnered with the College of Central Florida since March 2004, with an overarching goal of increasing access to dental care for underserved populations in Marion County. The college has an accredited Dental Assisting Program and the health department is pursuing national public health accreditation. The partnership created the Hampton Dental Clinic, located in the poorest zip code of the county. The clinic includes eight dental and two pre-clinic operatories. The Hampton campus was built by the college at a cost of $1,959,000. Equipment, instruments and supplies were purchased by the health department through a grant of $150,000 from the State of Florida in 2003. In-kind donations from the Marion County Dental Association contributed to the college Dental Assisting program. To assess progress in attaining the overarching goal, three objectives were defined: increased access to dental care for county residents at or below 125% Federal Poverty Level (FPL); offer standardized training in the clinical setting for dental assisting students, while providing dental care for students in the program at or below 125% FPL; and make the dental practice sustainable despite multiple budget cuts.Despite many challenges, the partnership has succeeded. The three objectives have been met. The number of unduplicated child patients has increased steadily from 436 in 2003-2004 to 1606 in 2011-2012 (nearly 5% of the target population). The standardized dental assisting training is being provided, along with provision of dental care for low income dental assisting students. The students have exceeded a 90% pass rate for the Dental Assisting National Board, with individual scores well above the national average. Sustainability has also been achieved. Both organizations have lower overhead costs and the clinic has been able to remain in operation even with three of eleven positions cut in 2012, and the advent of managed care. Since the creation of the partnership, children receive comprehensive oral health care including cleanings, fluoride treatment, fillings, endodontic treatment, and extractions. Services have increased from 4,114 in 2003-2004 to 14,392 in 2011-2012. This is nearly a 350% increase. The health department provides on average 7.9 services per patient - one of the highest in the state. The partnership enables us to treat a significantly greater number of patients than would otherwise be feasible due to the availability of Dental Assisting Program students and teaching staff. Most importantly, oral health education is provided to patients and their parents during appointments, and in school classrooms, day cares, and through table clinics offered by the college Dental Assisting Program students. The impact for the target populations is not only accessibility, but addresses the reality that preventive care is much less expensive than restorative care. The students are a great asset to the dental clinic staff, providing this much needed education. In addition, prior to the partnership the students were only able to shadow private dentists in the community. While some students were allowed to assist, others only observed, and techniques varied with each practice. By standardizing the learning experience in our clinic, the students are now taught the proper methods instead of having to unlearn dubious shortcuts. Chairside clinical hours have increased to 450 compared to the National Average of 298. Additionally, because of the partnership we discovered that some students needed significant dental treatment themselves. These students were able to obtain certification that they are at 125% of the FPL or lower, and eligible to apply for Medicaid. MCHD also made a commitment to treat these students regardless of their Medicaid status. The evidence based strategies used in developing this practice were based in part on relevant information from the Evidence-based Practice Centers (EPC) Program of the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research—AHCPR) reports and technology assessments; a review of data collected by the Agency for Health Care Administration (AHCA) for Medicaid eligibles; data from billing records in the Florida DOH Health Management System (HMS) used by all local health departments in Florida; and data comparisons provided by FIRS, a State of Florida data source populated from billing data that tracks and compares information among health departments. On the college Dental Assisting Program side, the strategies used were reviews and analysis of data collected on the number of chairside hours, procedures completed, student grades of classroom and clinical work, national examination passage rates, and employment placement rates. The college evaluation source is the American Dental Association (ADA) Survey Center 2009-2010 Survey of allied Dental Education.Data is continuously collected by the health department and Medicaid officials as part of the services provided. This data includes the number of individual patients, number of patient visits, age ranges, types of services provided, broken appointments, and homelessness status. The college Dental Assisting Director monitors the examination passage and job placement rates for dental assisting students. Data is analyzed and regularly shared at meetings of both organizations. The NACCHO databank was searched, and a comprehensive internet search was conducted. There are multiple health departments treating dental patients, and some health departments which allow student dentists to work in their clinic. For example, Boston has a similar program housed in a dental school. However; this practice differs from any existing model practices found in NACHO's Model Practices database and other similar databases because of the local health department's deliberate leverage of the experience gained from development of this practice to extend the efforts of a county-wide health improvement coalition to develop other community partnerships. This innovative practice differs from any existing practices found in NACHO's Model Practices database and other similar databases because of the synergistic use of this practice as a multiplier to increase community partnerships. This particular practice is a partnering of two different community organizations having dissimilar objectives (education vs. prevention and treatment); and different objectives (a local health department with the objective of providing quality dental care to underserved populations, and an accredited college with the objective of providing quality training to students at or below 125% FPL) that have made their partnership a model for the Marion County community public health improvement coalition’s efforts to reduce the negative public health impacts of a large number of social determinants that effect underserved populations. The successes achieved by our partnership are evident in the outcomes: 436 children and 386 adults were seen in 2003 before the inception of the program, and 1,606 children plus 357 adults were seen in 2011-2012. However, the greatest benefit has been for the entire county by spurring the community to act in a concerted way to improve the overall health of its citizens. While this practice is innovative because of the larger context in which it has evolved, and the broad-based community impact it has had and will continue to have, it should be noted that the successful partnering of these two entities in Marion County is partially enabled by the Florida Department of Health's national public health accreditation process in all 67 of its local health departments. The Public Health Accreditation Board (PHAB) Standards and Measures, Version 1.0 and the National Association of County and City Health Officials (NACCHO) MAPP, Accreditation Preparation, and Healthy Community Design Toolkits were valuable sources of guidance for continuous improvement and transformation of the practice into a model for other community partnerships.The NACCHO Mobilizing for Action through Planning and Partnerships (MAPP) and the two NACHO Toolboxes cited above, together with information obtained from the U.S. Department of Health and Human Services (HHS), Healthy People 2020 website were sources of information for development of this practice. The innovative use of the Health Department's accreditation process as a tool to facilitate development of the practice is highly recommended for consideration by other health departments, since the tools are made widely available to members by NACCHO. In summary, the significant manner in which this practice differs from other approaches used to address the public health issue is the synergistic approach used to achieve the partnership’s public health impact. The concept may provide potential benefits to other health departments that are considering such partnerships. The practice enhances the health department’s ability to increase access to preventive, restorative and emergency oral health care services for underserved populations. It also provides equal access to culturally and linguistically competent care, which is not available through other community providers.
The Marion County Health Department and College of Central Florida are the primary stakeholders in this practice. The partnership is also involved in a broad-based county public health improvement coalition of health care providers, academia, business and local government.The partners shared goal of increasing access to dental care for 34,306 Medicaid eligible public school children is based on data collected by the integrated Florida Department of Health that show dental care as the greatest unmet need among children in Marion County. In a bold move that proved to be a major factor in achieving the partnership’s goal, the College of Central Florida board voted to build the Hampton Dental Clinic on a new campus in the poorest zip code of the county. The startup costs included $1,959,000 provided by the college for construction on the Hampton Campus and in-kind donations from the Marion County Dental Association valued at $100,000. The health department obtained a grant of $150,000 from the State of Florida for the purchase of medical and computer equipment and instruments for the dental operatories and clerical areas of the clinic. The health department also appropriated sufficient funds to hire dentists, three certified dental assistants, and a receptionist. Three objectives were defined to evaluate progress in attaining the overarching goal: increase access to dental care for the target population; offer standardized training in the clinical setting for dental assisting students, while providing dental care for students in the program at or below 125% FPL; and make the dental practice sustainable despite multiple budget cuts. The number of specific tasks that were necessary to launch the dental practice was daunting. The list included: development of a strategy to obtain support from the college advisory board to build a new facility at the Hampton Campus, and how to allocate funds for the construction project (a similar strategy was needed to obtain the support of health department leadership for utilization of the resources required to operate a full-time dental clinic at a location remote from the health department’s main site); formulation of a plan for a successful partnership between the health department and the college; applications by the health department for grant money to equip the dental clinic; adaptation of existing administrative and treatment protocols for transition to a remote clinic setting that met both health department requirements and the accreditation standards for the college; enrollment of the first dental assisting class; establishment of quality assurance and quality improvement plans, and a protocol for regular review and revision of all of the above whenever deemed necessary by either partner. Identifying the need in Marion County for a sustainable public sector dental clinic housed with a teaching program was the initial step in forming the partnership. The College of Central Florida conducted its own needs assessment and found that dentists did need dental assistants but not dental hygienists. The health department used its comprehensive Community Health Needs Assessment to identify underserved populations in Marion County needing oral health care. Step two required the college advisory board to vote to build a new campus on the Hampton property. Step three entailed allocation of funds for the building project as well as soliciting a donation from the Marion County Dental Association. Step four included a dialogue between the health department and the college about the viability of a partnership. Step five called for a commitment by both partners to meet as often as necessary to review site plans and partnership considerations. Step six asked the health department’s dental clinic director to draft a partnership contract and have it reviewed by the legal departments of both partners, and then have it signed by authorized representatives of the health department and college. Step seven was the application of the health department dental director for a grant of $150,000 from the State of Florida to purchase computers, dental equipment, and instruments (which happily, was granted). Step eight entailed both programs occupying the new building and setting up the clinic. Step nine was the inaugural of dental patient treatment at the Hampton Dental Clinic. Step 10 was introduction of first class of Dental Assisting Program students into the Hampton Dental Clinic. Step 11 created the ongoing administrative and planning process to govern operations and relationships between the dental clinic director and the Dental Assisting Program Director. Step 12 created Standard Operating Procedures for the dental clinic. Step one was initiated in 2001, and steps two through seven occurred in 2002-2003. Step eight, the move to the new campus building, took place in March 2004. Step nine, the treatment of patients in the new dental clinic by health department dentists, began in May 2004. Step 10, introduction of Dental Assisting Program students into the dental clinic, took place in August 2004. The policy and operational considerations of Steps 11 and 12 began in March 2004 and continue to the present. The health of Marion County isn’t just a health department project. The entire community has to take ownership of its health. Much of the effort required to launch partnerships in the community has rested with the Community Health Improvement Plan Executive Steering Committee (the health department is a founding member); however, as new partners have been designated from businesses, state and local government, academia, philanthropic organizations, community and faith-based organizations, they help increase the momentum of our efforts to transform the health system in Marion County. The public health improvement coalition is comprised of the health department, the College of Central Florida, Munroe Regional Medical Center, the United Way of Marion County, Marion County Parks and Recreation, the Heart of Florida Health Center (a Federally Qualified Health Center), Ocala Health, Access to Healthcare, the Marion County Sheriff, the Centers (mental health provider), Ocala Community Care, and the Hospice of Marion County. The role of these stakeholders in planning and implementation of the dental practice is advisory and advocacy, lending the voice of opinion leaders to the partner’s continuous quest for monetary and in-kind support. The networking opportunity is of significant value to the partnership as well, and allows the partners to share information, suggested good practices for operational and fiscal management, and lesson learned. The health department helps foster collaboration with these community stakeholders through our membership on the Executive Steering Committee. The health department’s Office of Quality Assurance and Performance Improvement, Public Information Officer, and Health Education Manager maintain a close relationship with the committee, which also furthers the dental practice's goals through advocacy and in-kind support. The health department is also custodian of the Community Health Improvement Plan for Marion County.We recognize that the health department acting alone cannot match the collective strength of the community and its various institutions working together to improve health care and highly value the collaboration. As the county public health improvement coalition expands, we will continue to lead or participate in public meetings, seek advisory seats on non-profit organization and local government boards, and carry out other activities that will foster and help sustain the community coalition's efforts, including the dental practice.
As stated, the results obtained through the partnership have been gratifying for the health department, the College of Central Florida Board, and community stakeholders. Empirical data has shown the practice to be a success. The overarching goal of the practice is to increase access to dental care for underserved populations in Marion County. The partners selected the 34,306 Medicaid eligible public school children in Marion County as the target population for the Hampton Dental Clinic. The decision was based on data collected by the integrated Florida Department of Health that show dental care as the greatest unmet need among children, birth to age 20. The health department has historically failed to meet expectations for improving oral health, and is one of the state Surgeon General’s priorities. To assess progress in attaining the overarching goal, three objectives were defined: increased access to dental care for county residents at or below 125% Federal Poverty Level (FPL); ability to offer standardized training in the clinical setting for Dental Assisting Program students, while providing dental care for those students in the program at or below 125% FPL; and how sustainable is the dental practice despite multiple budget cuts. The dental clinic partnership’s first objective, to increase access to care for Marion County residents at or below 125% of the Federal Poverty Standards (FPL) and to provide dental care to Dental Assisting students at or below 125% FPL has been met, as shown by realization of the desired outcomes (increased access) supported by quantitative data. Three performance measures were used to evaluate achievement of this objective: 1. In the period October 2003 - September 2004 there were 436 unduplicated child patients treated in the dental clinic with a total of 4,114 services provided. By 2011-2012 the number of unduplicated child patients treated was 1,606 with 14,392 services provided. A graph has been provided showing the number of child patients treated from 2003-2011 and the cost to treat each patient. The graph also shows a statistically significant decrease in cost per patient that directly correlates to the opening of the clinic. The cost per patient was $570 in 2003-2004 before the collaboration and was $553 the following year after the clinic became operational. The costs have continued to decrease since, with a cost per patient of $220 in 2010-2011 (the most recent data available); 2. A suggestion box was placed in the dental clinic waiting room for patients to provide feedback about their perceptions of the quality of care received. The comments cards were reviewed by the dental director and the health department Office of Quality Assurance. Comments such as, "we like the quality care we receive, "we like the staff," "they are fast and friendly," "they take care of patients," and "no complaints" were the most frequent feedback received. Negative comments were few and usually related to wait times. Whether patient comments are positive or negative, the dental director follows up and shares the information with the college; 3. To date, X-Rays, examinations, cleanings, fluoride treatments, and fillings have been provided for two Dental Assisting students. Since these students are at or below 125% FPL, treatment represents increased access to care as defined in objective one, and removes a barrier that could prevent a Dental Assisting graduate from entering the workforce. Objective two, related to the standardization of learning in the clinical setting for the CF dental assisting students has also been met. The number of clinical hours for CF dental assisting students is 450 well above the national average of 298. The students have exceeded 90% pass rate for the Dental Assisting National Board with individual scores well exceeding the national average. This outstanding collaboration also allows the dental assisting students to have more clinical and laboratory experience bolstering their level of learning while serving our most fragile clientele.The clinical experience allows for almost 70% more clinical hours than the national average for dental assisting accredited programs. The placement rate after graduation also is very high with most students already having a position lined up for them upon graduation. With an unemployment rate of 11-14% in Marion County that is a huge benefit that the collaboration provides. In addition the collaboration provides "on the job training" for many of the students who then apply for a position at the Marion County Health Department Dental clinic. To date the clinic has hired a total of 12 students. Objective three, related to the sustainability of the partnership and the capacity to continue to maintain the joint dental clinic. The State of Florida as well as the nation has experienced a recession, with high unemployment high and a faltering economy. This has caused a loss of revenue for all concerned. Government, college, and school budgets have all been slashed, while health care needs within communities have increased. Each provider is being asked to do more with less. Layoffs have occurred at the health department and the dental clinic was forced to eliminate three positions. Managed care has arrived in the State of Florida. Health departments across the state are now receiving $60 less per visit than the amount received for the last 20 years. Programs have been eliminated or cut back. The college has faced similar challenges. With unemployment high in Marion County, more students are going back to school and educators are asked to teach more students with less funding. However, since this partnership shares overhead costs, it is more fiscally sound than either program could be on its own. The health department does not have to pay rent, electric, phone, utilities, some computer expenses, maintenance, or security. The college does not have to pay for additional instructional staff or travel to individual provider offices to monitor student proficiency. The college faculty currently consists of five persons: the program director, a preclinical instructor, a clinical instructor, and two part time didactic instructors who teach night classes. The college does not have to pay for supplies for the students assisting and learning in the dental clinic; nor does it have to pay a fee for students to learn in individual provider dental offices. Finally, the health department and dental assisting program share maintenance costs. For example, when a repair person is called to fix something in either program the other program director is contacted to see if they need anything during the same service call. Partnering shares overhead costs and helps keep both programs sustainable. The early cost benefit analysis made by the health department Office of Quality and Performance Improvement provided and indication that the partnership was fiscally viable, and regular data collection and analysis by that office served as a useful indicator to guide our fiscal management process month-to-month.Our team had a high expectation of success from the initiation of the partnership based on the health department’s analyses, which allowed us proceed with greater confidence than would have been possible with a bleaker outlook for sustainability. Frequent assessment (monthly) also allowed us to modify plans whenever this was indicated by trends in our data. For example, a drop in the student pass rate for the Dental Assisting National Board has prompted a greater emphasis on academic preparation within the Dental Assisting Program, and monitoring the number of dental patient per diem resulted in better staff scheduling. Therefore, an efficient and effective quality program is strongly recommended.
The partnership has worked well. Some minor lessons learned: use the data in the Community Health Needs Assessment (CHNA) to support the need for your practice; search for advocates in the community; seek the endorsement of the local board of county commissioners and chamber of commerce; be prepared to do whatever it takes to get the partnership going and remain healthy; just because it isn’t listed in your own job description does not mean someone else will assume responsibility; leaders need to serve and have an attitude of service; projects don't always get done exactly when or how you want them done, but they do get done; treat others like you would want them to treat you (the Golden Rule); don't be overdramatic; be especially careful what is said in emails, because not only is an email a public record, the recipient may totally misunderstand your intended message; do not try to “guard your turf”; both programs must preserve the joint goals and objectives, and not take an “us vs. them” approach; communicate regularly, not just when the program is experiencing a crisis (honest, continuing communication works best in any relationship, and it works for large coalitions of community partners as well).We have learned from our experience to be mindful that while the two programs need each other, the health of the community is paramount; and the partners should actively strive to help sustain community efforts to improve public health. A few other lessons learned: while each partner is busy with the many demands placed on us individually, a constant effort must be made to foster teamwork and trust; our staffs have discovered that emails in a crisis do not work; a strong focus on the overarching goal through staffing and funding changes, personal crises of individuals, dental assisting students who come and go, etc. has been a great enabler of sustainability for the partnership; we have learned to listen twice as much as we talk. A huge barrier experienced in fostering and growing the partnership was our ability to relate to each other’s unique issues and goals beyond the common focus, and our capacity to maintain the necessary level of cooperation. Assigning accountability for partnership liaison helped alleviate this problem. We believe the greatest lesson learned was about the renewed awareness this practice has created in Marion County of the concept that “Together We Can” achieve greater success than striving separately. As it states in our Community Health Improvement Plan, when state and local government, the private sector, education, philanthropic organizations, community and faith-based organizations, and concerned individuals join with the same goal, amazing result are obtained. Ultimately, the evidence that this practice is better than the several it replaced can be found in the data both partners gather on a regular basis. The dental clinic is providing more services to greater numbers of an underserved population of Medicaid eligible children. In the face of multiple changes over the past decade of collaboration, the partnership of the health department and the College of Central Florida continues to be successful. The College Board supports the partnership, and the Dental Assisting Program continues to be an important element of the dental clinic. The local health department has experienced significant budgetary cuts as a consequence of reduced state and county funding for public health to the point of surrendering adult and child primary care programs in Marion County to a Federally Qualified Health Center (FQHC); however the dental clinic partnership has experienced consistent service growth. Since dental care is a critical public health need in Marion County, we believe there will be an ongoing commitment by the health department to the practice.The Florida Department of Health has included a mandate in its agency strategic plan for each CHD to develop partnerships to address the county's health care needs, including oral health care provider roles in the community; and to identify and implement strategies to improve access to health care services. An early cost benefit analysis made by the health department Office of Quality and Performance Improvement provided indicators that the partnership would be fiscally viable for a minimum of two to five years, permitting our team to have a relatively high level of confidence from the beginning, which allowed us proceed with greater enthusiasm than would have been possible with a bleak outlook for sustainability. Thus, a cost benefit analysis is strongly recommended for practical reasons and as a morale factor for the staff involved. Ultimately both the College of Central Florida and the Marion County Health Department are under the jurisdiction of the State of Florida and both entities continue to be funded. The need for dental care and for dental assistants remains critical. Marion County is still an underserved county, and the program directors will continue to search for grants to help support the Hampton Dental Clinic. With the advent of managed dental care in the State of Florida, funding challenges are increasing but not at a crisis level. Despite a $60 decrease in funding for each Medicaid child, funds have been appropriated to keep the dental clinic solvent. In addition, the college Dental Assisting Program Director closely monitors the need for certified dental assistants in our community so that graduates are able to transition to employment or further education.
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