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Referral and Follow-Up

Referral and Follow-Up


Ensuring that students receive needed oral health care is challenging. A panel of experts was convened on May 11–12, 2006, in Washington, DC, to discuss strategies to overcoming barriers to accessing oral health care. The report from that panel, Improving the Oral Health of School-Aged Children: Strengthening School-Based Dental Sealant Program Linkages with Medicaid/SCHIP and Dental Homes, provides useful information. Following is a list of the types of strategies discussed at the meeting:

Case Management

Case management is a process whereby families receive help with finding and using oral health care services, including establishing dental homes. The process, overseen by a case manager, addresses any need or circumstance that may prevent students from receiving needed oral health services. Case managers must understand students’ oral health needs and must act to ensure that these needs are met. Activities undertaken by case managers include

  • Engaging parents in obtaining needed oral health care for their children
  • Enrolling students and their families in insurance plans (e.g., Medicaid, CHIP)
  • Helping families use their insurance coverage (e.g., filling out forms, following insurance-coverage policies)
  • Identifying dentists in the community who will accept students enrolled in Medicaid or CHIP
  • Setting up appointments
  • Educating students and their families on how to be good patients (e.g., calling dental office if unable to make appointment, arriving on time for appointments, appropriate waiting room behavior)
  • Arranging transportation
  • Obtaining translation services
  • Following up to ensure that needed oral health care was received

It is important to establish approaches for providing services based on the needs of the community in which the school-based dental sealant program operates. Case managers can include health and social service professionals (e.g., dental hygienists, dental assistants, school nurses, social workers), administrative staff, or volunteers. Case-management services and case managers’ levels of effort vary depending on the geographic and sociodemographic needs of the community as well as each case manager’s level of expertise.

The American Academy of Pediatric Dentistry’s Pediatric Oral Health Research & Policy Center offers a more in-depth discussion of the role of case management in the prevention and treatment of oral disease and describes various case-management strategies (e.g., motivational interviewing, education and health literacy, care coordination, community outreach and education, appointment-reminder systems).

Fixed-Site and Portable Clinics in School-Based Oral Health Programs

Boston’s Smart Smiles Program uses portable dental equipment to provide diagnostic, preventive, and limited comprehensive care shared by teams of dental hygienists and dentists. Initially, a dental hygiene team provides preventive and diagnostic services (e.g., screenings, examinations, oral prophylaxis, fluoride treatments, dental sealants, necessary X-rays). Once the dental hygiene team completes its work, a dental team provides more comprehensive treatment to students with oral disease. Students with clinical needs beyond those defined in the school-based scope of service are referred to fixed dental clinics in Boston’s community health centers, to the Tufts University School of Dental Medicine, to the Boston University School of Dental Medicine, or to the Harvard University Dental School.

School-based oral health programs can efficiently provide students with access to comprehensive services (e.g., oral prophylaxes, topical fluoride treatments, dental sealants, restorative care, education). Such services can be offered through fixed-site clinics, portable clinics, or a combination of the two.

Fixed-site clinics tend to offer comprehensive services to students, whereas portable clinics tend to provide preventive and basic diagnostic and restorative care (e.g., bitewing X-rays, restorations). Oral health professionals and their combined use of portable clinics and fixed-site clinics to conduct examinations and provide preventive care and advanced treatment can serve as effective dental homes for students who do not have them.

Mobile Dental Vans

Properly outfitted, mobile dental vans can provide comprehensive and ongoing oral health care to students living in geographic areas where fixed dental clinics may not be available (e.g., rural areas, urban areas). It is important for mobile dental van programs to identify a geographic area in which the program can meet the population’s oral health needs (e.g., provide routine preventive procedures, deliver restorative oral health care). Programs that serve overly large geographic areas (e.g., entire states, multiple counties) are generally not able to effectively serve as dental homes because there are times when the van is not accessible to those in need of immediate care.

Safety Net Dental Clinics

Cincinnati’s school-based dental sealant program refers and transports students without dental homes to the local health department’s dental clinic for needed follow-up care. Health department staff assist parents of children eligible for Medicaid or CHIP with enrollment, if needed, and the safety net dental clinic can establish an ongoing relationship to become the students’ dental home.

Creating links with oral health professionals in local safety net dental clinics is another approach for establishing dental homes for students participating in school-based dental sealant programs. Oral health professionals in safety-net dental clinics can provide comprehensive and ongoing oral health care to students from families with low incomes and to other underserved populations.

Safety net dental clinics are usually staffed by community-based oral health professionals and are generally located in areas that serve populations that face various access barriers, often including limited ability to pay for care. These clinics are frequently located in community settings such as public schools, community health centers, Indian Health Service clinics, public health departments, dental schools, hospitals, and private not-for-profit service agencies (e.g., social service agencies).

Other strategies include

  • Advocating, in collaboration with community coalitions, for competitive or market-based Medicaid and CHIP reimbursement rates and policies that allow for easier administration of the school-based dental sealant program.
  • Helping parents complete applications for Medicaid or CHIP, so that students have dental insurance.
  • Encouraging and mobilizing parents to take their child to the dentist; understanding the barriers faced by parents whose children are treated in school-based dental sealant programs (e.g., transportation, keeping appointments).
  • Addressing the communication and information needs of families from various cultural backgrounds who speak a primary language other than English.
  • Recruiting new dentists to participate in state Medicaid, Medicaid-managed-care oral health programs, and CHIP, and encouraging those already participating to treat children and adolescents.
  • Compiling lists of referral sources by neighborhood that have agreed to provide treatment to students participating in the school-based dental sealant program.
  • Partnering or collaborating with pediatric physicians or departments that have shown a disposition for recognizing the importance of oral health for overall health.

School-based dental sealant programs that wish to offer Medicaid and CHIP outreach activities may be able to obtain additional funding through the Medicaid administrative match process. The Medicaid administrative match can provide additional funding for Medicaid outreach activities that may include care coordination and referrals to other health professionals (medical or dental), provide eligibility applications to parents and students, and assist families in the Medicaid and CHIP application process.