Appointments are available during early morning, evening, and weekend hours in addition to typical business hours.
Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.
Experience when a person seeks and receives care, including elements such as ease or difficulty in getting appointments, accessing information, and communicating with health providers.
Community Needs Assessment
Community-level data are used to identify major oral health needs within the community.
Culturally Competent Care
Care is delivered in a manner that meets the social, cultural, and linguistic needs of people (1) in a manner the person understands.
Clear policies and user-friendly tools to support eligibility verification and continuity of eligibility in private and public programs. (2)
Mechanisms are established to support enrollment, including continuity of enrollment of pregnant women, infants, children, and adolescents, into private dental insurance coverage and public programs that provide oral health care coverage.
Establishment of a Medical-Dental Neighborhood that Provides a Supportive Environment Based on Needs
The medical-dental neighborhood is a clinical-community partnership that provides the medical, dental, and social supports necessary to enhance health, with the patient-centered medical home coordinated with the patient-centered dental home, serving as the primary “hub” and coordinator of health care delivery. (3) The medical-dental neighborhood is composed of a patient-centered medical home (PCMH), coordinated with a patient-centered dental home (PCDH), and the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations and state and local public health agencies. The PCMH, the PCDH, and the surrounding medical-dental neighborhood can focus on meeting the needs of patients but can also incorporate aspects of the health needs of the population and overall community in its objectives. (4)
Oral health care is provided using the judicious integration of systematic assessments of clinically relevant scientific evidence (evidence-based guidelines, relating to the person’s oral and medical condition and history, with the oral health provider’s clinical expertise and the person’s treatment needs and preferences).
Facilities and Equipment
Availability of health care facilities (e.g., hospitals, emergency departments, clinics, CHCs, medical offices, dental offices) and equipment (e.g., dental operatory, tele-dentistry equipment and technology to support a virtual dental home) that meet federal and state standards, along with state systems to monitor and certify quality and safety.
Health Information Technology
Interoperable health records and data aggregation technologies (including between private and public programs) (e.g., registries) across multiple levels of the health care system are in place to support care coordination, care continuity, referral systems, and data sharing along with the ability to report quality indicators at each level of the health care system (e.g., dental sealants provided to children and adolescents enrolled in Medicaid in school-based programs should be accounted for). Providers should be able to access data on quality or performance indicators (e.g., via practice and/or systems dashboards).
The degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. (5)
The health state of a person or change in health state resulting from health care.
Leadership Coordination Program leaders work across programs in the state to optimize resources, services, and supports.
Level of Funding
Adequate funding and appropriate reimbursement policies are established based upon actuarially sound methodologies.
Any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient's response.
Person- /Family-Centered Care
The provision of care that is respectful of, and responsive to, person and/or family contextual elements, preferences, needs, and values and that ensures that the person’s and/or family’s values guide all clinical decisions.
Policy Linked with Evidence
Effective, evidence-based policies are in place that support the provision of oral health care services for improving oral health for pregnant women and children.
The availability of providers to ensure that benefits for beneficiaries are accessible without unreasonable travel or time delays.
Clinical providers and non-clinical team members receive training that incorporates evidence-based guidelines, integration of oral health care and primary health care, caring for diverse populations, and quality-improvement principles and methodologies.
Pregnant women, infants, children, and adolescents receive appropriate referrals for recommended care.
Scope of Benefits
Coverage of services based on nationally recognized guidelines, recommendations, and regulations (e.g., Bright Futures; Early and Periodic Screening, Diagnostic, and Treatment [EPSDT]; U.S. Preventive Services Task Force) for oral disease prevention and oral health promotion.
Scope of Services
Range of services provided to pregnant women and children of various ages.
Service-Delivery Partnerships in Community Sites
Services are provided in community-based clinical settings and/or in conjunction with other organizations or programs.
Site of Care (indicator)
Timely care provided in an appropriate setting.
Transitions to Adulthood
Adolescents receive services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence (e.g., care for adolescent with special health care needs). (2)
Accessible and affordable transportation services are available to connect patients to care sites.
Use of Services (indicator)
Provision and utilization of services by a group of individuals identified by enrollment in a health plan or through use of clinical services. (6)
1. Betancourt JR, Green AR, Carrillo JE. 2002. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. New York, NY: The Commonwealth Fund.
2. Definitions adapted from Association of Maternal and Child Health Programs. 2014. Standards for Systems of Care for Children and Youth with Special Health Care Needs.
3. Adapted from Patient-Centered Primary Care Collaborative. 2018. Medical Neighborhood [webpage].
4. Adapted from Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. 2011. Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms—White Paper. Rockville, MD: Agency for Healthcare Research and Quality.
5. Office of Disease Prevention and Health Promotion. 2010. Quick Guide for Health Literacy. Rockville, MD: Office of Disease Prevention and Health Promotion.