Young Children Priority One Dental Program

State: NE Type: Model Practice Year: 2013

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Two Rivers Public Health Department(TRPHD) serves 94,797 people in seven counties in rural Nebraska. There are 6944 children from 0-4 years of age with 534 infants and 2765 children eligible for the WIC program. Each dentist in TRPHD serves approximately 1843 patients, many are close to retirement and do not accept Medicaid patients. In 2010,Gosper, Harlan, and Franklin in TRPHD were identified as having dental health workforce shortages. According to the most current estimates, more than 40% of U.S. children ages two to 11 have decay in their baby teeth, and among all children ages 6-18, about 25% have untreated decay (Kaiser Commission Policy Brief 2012 -NIDCR/NIH/NHANES 2004). Only 4 communities in TRPHD have fluoridated water. The Nebraska Open Mouth survey (2005) indicated that 60% of third graders had dental decay and 17% have untreated dental decay. From 2004 through 2012, 482 children in the TRPHD district without access to dental care were screened by volunteer dental professionals and 437 received treatment during the UNMC College of Dentistry’s "Dental Day". A total of 4,158 procedures have been performed at an estimated value of $200,000.

 

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Two Rivers Public Health Department
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Young Children Priority One Dental Program
Two Rivers Public Health Department(TRPHD) serves 94,797 people in seven counties in rural Nebraska. There are 6944 children from 0-4 years of age with 534 infants and 2765 children eligible for the WIC program. Each dentist in TRPHD serves approximately 1843 patients, many are close to retirement and do not accept Medicaid patients. In 2010,Gosper, Harlan, and Franklin in TRPHD were identified as having dental health workforce shortages. According to the most current estimates, more than 40% of U.S. children ages two to 11 have decay in their baby teeth, and among all children ages 6-18, about 25% have untreated decay (Kaiser Commission Policy Brief 2012 -NIDCR/NIH/NHANES 2004). Only 4 communities in TRPHD have fluoridated water. The Nebraska Open Mouth survey (2005) indicated that 60% of third graders had dental decay and 17% have untreated dental decay. From 2004 through 2012, 482 children in the TRPHD district without access to dental care were screened by volunteer dental professionals and 437 received treatment during the UNMC College of Dentistry’s "Dental Day". A total of 4,158 procedures have been performed at an estimated value of $200,000. In April 2012, the Ronald McDonald Dental Van provided treatment to 79 patients in Lexington at an estimated value of $22,000 The Goals of the Young Children Priority One(YCPO) program are to improve access to preventive dental care by: 1)Providing oral care instruction and supplies to high risk children and families on a quarterly basis, 2) Application of inexpensive topical treatments to prevent decay (iodine, fluoride varnish)3 to4times/year utilizing a Dental Hygienist with Certification in Public Health. The dental program is provided to children and their families in WIC clinics, Head Start, preschools, and elementary schools. A Dental Hygienist provides a more economical dental professional for service delivery. YCPO was the model for the Oral Health Access for Young Children Program (OHAC) which was funded by Nebraska DHHS in 2011-2012. OHAC included 12 local health departments and served 13,989 children under 5 years and provided 22,973 fluoride treatments. YCPO was developed with Dr. Peter Milgrom, from the University of Washington who investigated the effectiveness of dual fluoride/antimicrobial therapy on caries prevention or reversal in young children. Topical fluoride varnish is also recommended by HRSA for children at high risk for caries. (Summary of Evidence for Use of PVP Iodine for Caries, Milgrom, 2-29-2008) YCPO began in August 2008 with a $57,000 grant from Nebraska DHHS which utilized PHHS block grant funding, subsequent funding was received from HRSA and our most recent grant is from Title V/MCH funding. Information below documents the growth and expansion of the program. In 2009, the YCPO programs provided services to the following: • Lexington: 144 Women, 200 Children 81% Hispanic 16% White 3% other • Kearney: 94 Women, 57 Children, 56% white, 44% Hispanic In 2010: • WIC Kearney: 181 Women 284 Children, • Lexington: 285 Women, 329 Children • Holdrege: 57 Women, 111 Children • 470 children in the preschool programs. In 2011: • Children: 1547 total Gibbon 171, Holdrege 244, Kearney 280, Lexington 852 • Adults: 613 • Total number of fluoride treatments: 1979 In 2012: •Children: 415 (0-1 yr) 743 (2-3 yr) 1438 (4-5 yr) 54 (6-8yr) 35 (9-13 yr) total – 2,685 •Adults – 1,024 •Fluoride treatments – 3,249 .Treatment locations include Gibbon, Kearney, Lexington and Holdrege  YCPO will continue to use the processes that Creighton University developed for evaluation. District School nurses report a decrease in decay after YCPO was started and shared the following data: Lexington, NE Preschool/Kindergarten Dental Referrals Preschool/ Kindergarten 2006-2007 - 19 (182) 10.4% 15 (220) 6.8% 2007-2008 - 21 (195) 10.8% 22 (239) 9.2% 2008-2009 - 31 (193) 16.0% 41 (234) 17.5% YCPO began seeing patients in December 2008 and January 2009* 2009-2010 - 43 (181) 23.8% 31 (231) 13.4% 2010-2011 - 39 (243) 16.0% 20 (230) 8.7% 2011-2012 - 22 (265) 8.3% 32 (232) 13.8% *These numbers do not always reflect the same children from one grade to the next as the population is somewhat transient. Gibbon, Nebraska During 2007, 35 children of 113 screened needed dental care. During 2008, 35 of 98 children screened needed dental care. Gibbon 2012 dental screenings showed the following improvements: Kindergarten 7 needed to be referred out of 50 students, 14% 1st graders 8 out of 49 students, 16.3%; 2nd graders 3 referred out of 49 students, 6.1%; 3rd graders 8 referred out of 53 students, 15.1%. YCPO has grown due to our enthusiastic and dedicated partnerships and is showing positive results.
Responsiveness The public health issue that this practice addressesAccording to the U.S. Surgeon General's Oral Health in America report May 2005, tooth decay is the single most common chronic childhood disease; five times more common than asthma and 7X more common that hay fever. The report found lack of awareness of the importance of oral health among the public and a significant disparity between racial and socioeconomic groups in oral health and overall health issues. The Surgeon General called for action to promote access to oral health care, especially the disadvantaged and minority children that are at greatest risk for severe medical complications resulting from minimal oral care and treatment. The American Academy of Pediatric Dentistry, American Dental Association and American Academy of Pediatrics all recommend that low-income, high risk children be seen to assess dental caries experience by the age of one year. Healthy People 2020 Objectives target the following priorities which YCPO addresses: 1) Increase the proportion of local health departments that have oral health prevention or care programs 2) Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth and 3) Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year. Most private practice dental providers in the TRPHD district do not see Medicaid patients. Dental services are also not included in Nebraska's newly established Medicaid Managed Care program. We have one pedodontist in our district(children's dentist) with two more than an hour or more away. Our patient to Dentist ratio averages 1843 with a high of 3103 patients to a low of 1512. Nebraska developed a Head Start Dental Home Initiative to increase the number of Head Start children that have dental homes, but it has not been very successful. We have recently lost our State Dental Director and Nebraska did not receive HRSA funding to continue the Oral Health Access for Young Children Dental program that funded "Program in a Box" preventive services in 12 local health departments across the state. YCPO was used as the model to develop this network. The process used to determine the relevancy of the public health issue to the communitySeveral processes were undertaken to determine the relevancy of dental access to our district. TRPHD completed the Mobilizing for Action through Planning and Partnership in 2007 and 2012. Access to Care, including dental care was identified in each of the assessments as a priority. YCPO was developed following the first MAPP assessment and the need to continue the program was reinforced in 2012. The Nebraska 2005 Open Mouth Survey of Third Graders demonstrated that 60% of Nebraska third graders had tooth decay and 17% of this decay was untreated. Dye et al 2007 suggest that tooth decay in two to five year olds is increasing with 28% having untreated decay. Nebraska recommendations from the Open Mouth Survey included efforts to educate families about the importance of oral health, especially pregnant and new mothers, increased access to preventive dental care, especially for at-risk populations and education about fluoride applications for the pubic and professionals. TRPHD has partnered with local schools, dental professionals and the University of Nebraska College of Dentistry from 2004-2012 to provide dental screenings and treatment to 404 children that had no access to dental care. The children are from the Lexington community and we have dental needs in all of our communities. We have also partnered with the Ronald McDonald Dental Van which is owned by One World Community Health Center in Omaha to provide dental care one week each year to children in Lexington and Kearney. The Nebraska Dental Association has organized Mission of Mercy events to provide free dental care and these events always present more needs that providers and services. We receive daily calls at the health department seeking dental care and refer them to a sliding fee scale clinic 1 1/2 hours away or FQHCs that are over 2 hours away. How the practice addresses the issueThe Young Children Priority One program focuses on education combined with preventive therapy and the distribution of toothbrushes and fluoride toothpaste to clients in various public health settings which are non-traditional for dental care. The primary focus locations are: 1) WIC and related programs which provide services to new mothers, their children and families, 2) Early Health Start and Pre-School classes for ages 2-3 years, Head Start classes for ages 4-5, and elementary schools, ages K-1. The program was initially developed and directed by Dr. Karen Sorenson, DDS, a Public Health Dentist who provided her services as in kind and was serving on the Board of Health of Two Rivers Public Health Department. Lower cost professionals are used to deliver the services: dental hygienists with certification in public health, dental program assistants, interpreters and the program is taken to the patients.   Innovation Evidence based strategies used in developing this practiceYoung Children Priority One Dental Program was developed with consultation from Dr. Peter Milgrom, from the University of Washington who investigated the effectiveness of dual fluoride/antimicrobial therapy on caries prevention or reversal in young children. EARLY CHILDHOOD CARIES A TEAM APPROACH TO PREVENTION by Peter Milgrom DDS, and Philip Weinstein PhD J Dent Child (Chic). 2011 Sep-Dec;78(3):143-7. Topical iodine and fluoride varnish effectiveness in the primary dentition: a quasi-experimental study. Milgrom PM, Tut OK, Mancl LA. Topical fluoride varnish is also recommended by HRSA for children at high risk for caries. (Summary of Evidence for Use of PVP Iodine for Caries, Milgrom, 2-29-2008) Process used to determine that the practice was new to the field of public healthProvision of preventive dental services is not a new or innovative program. Provision of the services to very young children, before the age of three and prior to entry to school is relatively new and not well accepted by the private practice dental profession. Delivery of services out of the private practice setting and in public health and educational settings such as WIC and Head Start is also relatively new. Young Children Priority One Dental Program is using evidence based preventive dental practices, with the addition of povidone iodine as an antibacterial with fluoride varnish. We are also utilizing a relatively new dental professional. The dental hygienist with public health certification was first licensed in 2007. This provided an economical dental professional that could work in public health settings without the supervision of a dentist. The partnerships developed with WIC, Head Start, Public Schools and other partners have provided non-traditional settings to provide the preventive dental program to the high risk populations.What tool or practice was used in a creative wayMAPP was utilized by TRPHD to identify access to dental care as a priority in both 2007 and 2012. The Young Children Priority One Dental Program is included on the NACCHO website as a Promising Practice as of 2012 in Maternal and Child Health. How this practice differs from other approaches used to address this public health issueThe YCPO program was used as a model to develop the "Program in a Box" preventive dental program that was the framework for the Oral Health Access for Young Children network that was developed in Nebraska. This program included 15 local health departments/FQHCs that provided comparable programming in WIC, Head Start and preschool programs across the state with HRSA funding in 2011-2012. Young Children Priority One is similar in goals and practices to three previous NACCHO model practices: Early Childhood Cavity Prevention Program in Klamath County 2007 WIC-Dental Partnership for Prevention 2008 and Dental Initiative 2010. Young Children differs from these prgrams in utilizing an antibacterial in addition to the oral health education and supplies and fluoride varnish application. It also strives to provide these services 3-4 times a year. The importance of including families is paramount in stopping the transmission of caries from caregivers to children and in the establishment of dental knowledge and health habits. Another addition to our program is the expanded partners and sites where the program is offered, Head Start, Early Head Start and Preschools. One additional difference is the use of the Dental Hygienist with Certification in Public Health which allows the professional to practice in public health settings without the supervision of a dentist. This decreases the cost of the program substantially.
Primary StakeholdersThe primary stakeholders are the children and their families at high risk of dental decay, dental hygienists, dental assistants, dental program assistants, dentists, WIC, Head Start/Early Head Start, Preschools, Elementary Schools, Two Rivers Public Health Department, University of Nebraska College of Dentistry LHD RoleTRPHD serves as the program manager and fiscal agent for YCPO. The health department also serves as a connector of the dental professionals and the public health programs and public health system, the Community Action Agency and funding sources. TRPHD contracts with the dental personnel and provides in kind fiscal and administrative support for the personnel and the grant. Stakeholder/PartnersAll of the partners have been involved in the planning and implementation of the practice. It has continued to grow from its original inception and development with Dr. Karen Sorenson and guidance and technical assistance from Dr. Peter Milgrom. The program undergoes continuous quality improvement with changes being documented and incorporated as they are needed. Fiscal resources are always monitored and fiscally responsible decisions on their distribution are made. Joint meetings are held with dental personnel, TRPHD, WIC, Head Start, interpreters, etc to assure the program is inclusive and functioning well. This group also determines the growth and expansion of the program and contributes to the funding application process. TRPHD and Community Action Partnership of Mid Nebraska, which oversees the WIC and Head Start programs in the area, have a formal MOU to document the relationship and partnership of the programs. TRPHD is the facilitator of the process - we are familiar with and work with all of the partners and initiate the relationship building and partnership formation. Ongoing communication is vital with all of the partners to assure that needs are being met within the resources that are available. The dental professionals provide oral health education to the partners prior to beginning programs to assure that the teachers and other professionals are aware of what is being taught and how it relates to their mission of serving the children. Our WIC Director has gone from being wary of what chaos we were going to cause in her clinic to being our biggest advocate and helping to spread the Oral Health Access for Young Children program into WIC programs across the state. The dental professionals also realize that they are invited guests of the locations they partner with and provide their services in a respectful and culturally competent manner. Lessons LearnedThe dental professionals provide oral health education to the partners prior to beginning programs to assure that the teachers and other professionals are aware of what is being taught and how it relates to their mission of serving the children. Our WIC Director has gone from being wary of what chaos we were going to cause in her clinic to being our biggest advocate and helping to spread the Oral Health Access for Young Children program into WIC programs across the state. Our barrier is not in developing the collaborations or finding new partners to work with and venues to hold clinics. Our barrier is in acquiring sustainable funding to continue our program and provide the access to preventive dental services that is needed by our high risk population.   ImplementationServices offered to at risk pregnant mothers, primary caregivers of young children, children birth to age 21 as well as children with special needs are oral health education as well as education on correlating systemic factors, oral screenings, fluoride varnish and antimicrobial applications and dispensing of homecare supplies. All services are provided on a 2 month follow-up interval at Kearney, Gibbon, Lexington, Holdrege and Minden WIC sites. Supplies provided include: Tooth brushes Toothpaste Povidone iodine Fluoride varnish Dental education supplies, evaluation forms and patient records, interpreters and translated documents Services provided for high risk children attending identified preschools, Title 1 elementary schools, Early Head Start and Head Start programs are oral health education, fluoride varnish, antimicrobial applications, oral screenings and dispensing of homecare supplies, and dental sealants when indicated by risk assessment. Services are provided at 2 to 3 month intervals at Kearney, Gibbon, Lexington, Holdrege and Minden. Supplies provided include: Tooth brushes Toothpaste Povidone iodine Fluoride varnish, dental sealants, Dental education supplies, evaluation forms and patient records Time frameThe clinics for which the data is reported is from January 2011 through August 2012. These services were provided by HRSA funding which was obtained through the Nebraska DHHS Office of Oral Health and Dentistry. YCPO emphasizes oral health education and supplies, application of povidone iodine(antibacterial) and fluoride varnish three to four times a year, with an emphasis on in-school and home brushing. The dental program is provided to very young children and their families in locations where the children and families are already present - not the dental private practice setting. YCPO programs are delivered with WIC clinics, Head Start and Early Head Start programs, preschools, and elementary schools. A Nebraska Dental Hygienist with Public Health Certification which is licensed to provide these services in public health settings is utilized for the program which provides a more economical dental professional for service delivery. This certification was recently approved by the State of Nebraska in 2008 to improve access to dental care in public health settings. YCPO was developed as a pilot program with Preventive Health and Health Services Block grant funding in December 2009/2010/2011 and has served as the model for the Oral Health Access for Young Children Program (OHAC) which has been developed and funded by NDHHS in 2011/2012 with the use of Health Resource Services Administration (HRSA) funding. We are currently operating 2012/2014 with a recently received grant through Maternal and Child Health Funding from Nebraska DHHS. Lessons LearnedOur program has always focused on provision of preventive dental services to the high risk children and families in the Two Rivers PHD District. We have continued the quality improvement process throughout the program which has effected all processes and protocols including form development, supply ordering and storage, clinic staff, interpreters(recruiting, education, compensation), collaboration with partners, scheduling, clinic flow and processes, and multiple other refinements. We have also learned that sustainability is a huge concern, which is evident in the multiple funding sources we have tapped to keep our program going and growing. We continue to research more ways to keep our program operating. The program initially included an in school toothbrushing program which was operating for 4 years with PHHS funding. We have had to stop our support of this program due to decreased funding. The school nurses in Gibbon and Lexington are seeking funding for continuation through the United Way and local service organizations because they know the program is of value to their students. In January 2011, OHAYC was implemented by 15 grantees representing Nebraska local health departments and FQHCs. By August 2011, these 15 grantees implemented the program in 31 local communities at 43 individual sites; By August 2012 the intervention grew to 37 local communities at 53 individual sites. Between August 2011 and August 2012, the average number of patients seen per month rose by 23% from 1,137 to 1,477. In total, this program provided dental screening and referrals, oral health education and 23,706 fluoride varnish applications among 16,741 patients through 6,813 clinical hours and the work of 62 individuals supported by this program. Of the clinical patient encounters, 7,991 were repeat visits. Cost of ImplementationOur initial grant provided $57,000 to cover the costs of dental contractors, supplies, mileage, printing, interpreters. Two Rivers has always provided support as in kind, as has Dr. Karen Sorenson, DDS. This amount of funding allowed us to provide prevntive dental services to 1575 children and 460 adults in 2010. In-kind was not required by our funding source. Our HRSA funding totaled $71,000 per year and included costs for personnel (interpreters), mileage, supplies (approximately $4 per patient) dental professional contractors, opies, computer maintenance, clinic space and indirect. HRSA required 40% in-kind match. This funding provided 3249 preventive dental treatments (oral health education and supplies, screening, povidone idodine and fluoride varnish) to children and adults in 2012 at our partner sites: WIC, Head Start, and public schools in four communities in the Two Rivers District. 1158 of these treatments were provided to children age 3 and under which are not routinely seen by private practice dental offices in our district.
Evaluation measures were collected on the following data: Process Evaluation: 1)Location of clinic,2) number of pediatric patients seen by age range,3)number of adults seen,4)total number of fluoride varnish treatments given,5) total number of patient visits,6)total hours worked.   Outcome Evaluation: Rates and costs were compared from Year One to Year 2 Participant Satisfaction with the program was also evaluated The children served ranged from 3 days to 13 years old. Race/Ethnicity*: 46.9% Hispanic 40.3% White 9.7% Black/African American 1.6% American Indian .8% Asian .7% Other (*These statistics were for the 15 programs across the State of NE) For YCPO 19.4% had unhealthy gums 27.7% had early childhood caries 18.6% needed further care 59.3% of the children had no dental home 68.2% of the children were on Medicaid 81.5% had no dental insurance Information was received from school nurses in two of the participating schools: Gibbon 2012 dental screenings: Kindergarten 7 needed to be referred out of 50 students, 14% 1st graders 8 out of 49 students, 16.3%; 2nd graders 3 referred out of 49 students, 6.1%; 3rd graders 8 referred out of 53 students, 15.1%. Lexington, NE Preschool/Kindergarten Dental Referrals Preschool/ Kindergarten 2006-2007 - 19 (182) 10.4% 15 (220) 6.8% 2007-2008 - 21 "(195) 10.8% 22 " (239) 9.2% 2008-2009 - 31 "(193) 16.0% 41 "(234) 17.5% YCPO began seeing patients in December 2008 and January 2009* 2009-2010 - 43 "(181) 23.8% 31 " (231) 13.4% 2010-2011 - 39 "(243) 16.0% 20 " (230) 8.7% 2011-2012 - 22 " (265) 8.3% 32 " (232) 13.8% These numbers do not always reflect the same children from one grade to the next as some preschool children move away and don’t go to Kindergarten and some of the Kindergarten students move into Lexington at that time. These screenings/referrals are done by the Lexington School RNs. *Children began receiving preventive YCPO dental treatments in the Lexington WIC and Head Start programs as well as the Preschool at this time.   Objective 1:Evaluation measures were collected on the following data: 1)Location of clinic, 2) number of pediatric patients seen by age range, 3)number of adults seen, 4)total number of fluoride varnish treatments given, 5) total number of patient visits, 6)total hours worked. YC-PO 0-1 415 2-3 743 4-5 1438 6-8 54 9-13 35 adult 1024 fl 3249 hours 561.5 Evaluation measures by program: WIC: total patients - 2986, fluoride varnish - 2862, total hours 868.25, patients per hour - 3.44 Head Start: total patients-599, fluoride varnish -581, total hours - 29.66, patients per hour - 20.20 Preschool: total patients - 1465, fluoride varnish - 1435, total hours - 37.5, patients per hour - 39.07 Objective 2:Rate comparisons were also evaluated. The Two Rivers YCPO program was compared to the average of the 15 programs in the Oral Health Access for Young Children in Nebraska. Year One was from January 2011-August 2011 and Year Two was from September 2011-August 2012. This corresponded to the HRSA funding that was granted for the programs. Average TRPHD YCPO Patients per hourYear 1 3.60 5.11Year 2 3.98 5.92 YCPO saw an average of 1.73 more patients per hour than other programs Ave $/Patient Year 1 38.42 31.79 Year 2 20.50 19.95 YCPO spend an overage of $3.59 less per patient than other programs. Ave $/Clinic hour Year 1 138.16 162.49 Year 2 81.65 118.06 YCPO spent an overage of $30.37 more per clinic hour than other programs. Ave Min/Patient Year 1 16.7 11.7 Year 2 15.1 10.1 YCPO spent an average of 4.95 minutes less per patient than other programs. Justifications for the increased $/clinic hour for the YCPO program is due to the increased mileage required when providing the program at multiple sites across the seven county health district. The dental contractors live in various communities and most are not located in the same community that the clinics are held. Travel time and mileage expense both add to the expenses of operating the clinics. Two Rivers Public Health Department District (TRPHD) covers 4,579 miles and is primarily rural. Our dental hygienists and clinic staff also refined protocol and procedures to improve clinic efficiencies and time management to improve clinic flow and patient satisfaction as well as satisfaction of the partners they were working with. The bulk ordering by the State of Nebraska of dental supplies helped decrease the supply expense of the programs. Objective 3:Patient satisfaction was evaluated in the YCPO WIC program. A total of 800 surveys were received indicating that 950 children were seen for a dental visit. The minimum was less than 1 week and maximum age was 13 years with a median age of 2 years and an average age of 2.61 years. When parents were asked if they take their children to the dentist, 37% indicate that they take all of their children, 2% some of children and 43% none of their children. Of those that specified that they take their children to the dentist, 88% indicate that they take their children to the same dentist for return visits. Satisfaction was evaluated on the following questions: 1)How would you rate your overall level of satisfaction with the service you and your child received? 91.9% were very satisfied or satisfied with their service 2)How likely are you to refer others to this program? 80% were likely and 13.1% Already had referred others How confident are you that you can prevent cavities in your child's teeth? 80.3% were either very confident or confident
Stakeholder CommitmentWe were approached by our partners to apply for our current MCH funding to be able to continue our program for two more years because they see the value of our program and its benefits for their program participants. The Title One Elementary schools that were previously included in our toothbrushing programs are in the process of seeking funding through the United Way and service organizations such as Rotary to continue the programs they value and see the benefits of. This will be an ongoing process. We are part of the Nebraska Oral Health Coalition which is organizing with the goal of identifying stakeholders, resources and funding sources to support dental health in Nebraska. The hygienists and program professionals are very committed to this program, as are the recipients of the program - WIC, Head Start and Education staff and the children and adults that are being served. SustainabilityWe continue to search for funding sources to sustain and grow our program. We are on our third grant funding source at this time. We began the program with PHHS funding, moved to HRSA funding and have recently been awarded MCH funding for the next two years. We are investigating billing Medicaid for the services that are covered, such as fluoride varnish application. We are utilizing a cost effective professional - the dental hygienist with public health certification - as the service provider in the program and providing the program outside of the private practice office in public health settings. We continue to work with our legislators to share our programs successes in meeting one of the priority needs that have been identified in our district and statewide. Our program was previously used as a model for a statewide preventive dental health program "Oral Health Access for Young Children" that was supported by HRSA funding to Nebraska. Because Nebraska did not receive continuation funding for this program and the Nebraska DHHS Office of Oral Health and Dentistry, the entire program is no longer active. Nebraska State Dental Director position is also vacant at this time. All of the has a direct effect on funding and coordination for addressing the dental needs in the state. The Director of TRPHD and the dental hygienist that serves as the Program Coordinator are both members of the Nebraska Oral Health Coalition which is organizing with the goal of identifying stakeholders, resources and potential funding sources to support dental health in Nebraska. The TRPHD Director and all of the dental hygienists working with the program are also members of the American Dental Hygienists Association and Nebraska Dental Hygienists Association. The TRPHD Director is also a member of the Nebraska Association of Local Health Directors and access to dental care is a priority need of all of the local health departments.
 
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