Design Payment Transformation

The University of Washington and Advantage Dental Connecting Low-income Mothers and Children to Comprehensive Dental Care

Challenge

Low-income mothers and children in Oregon have low rates of dental care, and rates of tooth decay in young children are higher than the national average. Advantage Dental, a cooperatively owned dental care network, is changing its payment and delivery model in order to extend service to disdvantaged mothers and children in rural areas.

Partners:

University of Washington Northwest Center to Reduce Oral Health Disparities
Advantage Dental Services (owned by Advantage Community Holding Company, LLC)

Setting

Oregon is one of two states with the lowest dental care utilization rates in the nation. Only 10 percent of Medicaid/CHIP-enrolled children in Oregon receive the recommended dental care visit when they turn 1 year old, and only 39% of Oregon Health Plan-eligible children and 43% of eligible pregnant women received any form of preventive dental service in 2014.

Coordinated Outreach and Incentives How it Works

The University of Washington

To increase dental care utilization and decrease the incidence of oral health problems among Medicaid and CHIP-enrolled (Oregon Health Plan) mothers and children, Advantage utilizes expanded-practice dental hygienists (EPDHs) to screen and treat patients individually in community settings including schools and WIC and Head Start offices. Case managers coordinate care for patients with immediate needs to make sure they’re seen by a primary care dentist or clinic, and ensure patients are re-assessed at appropriate intervals. Regional manager community liaisons (RMCLs) coordinate community outreach and partnerships, including community education initiatives. A per-patient global budgeting program with pay-for-performance incentives rewards efficient and coordinated patient care.

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Patient participants

Advantage serves 82,000 pregnant women, children, and new mothers enrolled in the Oregon Health Plan across 14 rural Oregon counties; the intervention takes place in six of these counties (Deschutes, Douglas, Jackson-Josephine, Klamath, Morrow, and Wasco).

Intervention team

The intervention team for each county includes all Advantage-affiliated clinics and dentists in that county; one or more EPDHs who work in the community; and a regional manager community liaison (RMCL), who coordinates partnerships with community organizations and oversees EPDHs. An administrative team works across counties and includes case managers who connect patients with identified needs to services in a clinical setting, IT administrators, and other administrative staff.

Payment incentive and budgeting

Advantage employs a global budgeting capitation model, pooling the fixed payments it receives per patient. This enables funds to be directed toward innovative care models. Of the approximately $6.9 million allocated to Advantage through the Oregon Health Plan (Medicaid), the company directs a little over 2% into a bonus pool that is disbursed to the county team (EPDHs and dentists) for reaching goals of increased screening, in-field treatment of at-risk patients, and follow-up care in target counties, and which is also disbursed to the care coordinators and RMCLs if all counties meet the targets.

Tools for success

Community-based outreach

EPDHs screen and treat patients at schools and other sites through partnerships with community organizations.

Dental home

High-risk patients identified in community settings are provided seamless access to dentists in solo practices and clinics.

Root cause analysis

Surveys of providers and patients pinpoint potential causes of low care utilization rates. Follow-up discussions with stakeholders produce action steps.

Risk-based system

All patients are screened individually, and those at risk receive silver diamine fluoride treatment, follow-up care, and, if necessary, referral to a dental home.

Silver diamine fluoride

This cost-effective topical medication effectively arrests dental cavities, treating the underlying disease, and can be applied in community settings by EPDHs.

Electronic Health Record

ADIN, the EHR used by Advantage, enables information sharing among case managers, dentists and clinics, and care teams in the field. For example, it notifies case managers when a patient has been flagged for follow-up care.

Performance data

Monthly updates on patients seen and patients requiring care enable incentive payments and allow staff to measure their progress and understand where greater efforts are needed. Target metrics for receiving the bonus payment are adjusted upward each quarter.

Finding Answers: Solving Disparities Through Payment and Delivery System Reform is a national program funded by the Robert Wood Johnson Foundation with technical assistance and direction provided by the University of Chicago. Finding Answers was created to discover and disseminate practical ways to achieve health equity and is currently focused on discovering how healthcare payment and delivery systems can be redesigned to reduce and eliminate health care disparities. Its current work includes three pilot projects involving health systems and payers partnering to improve health equity.