In this section you will find descriptions of five different models of the WIC: Early Entry into Dental Care Program in California, each unique in the way it provides oral health services with WIC.
There are many different ways to implement a preventive dental care program with WIC. Which model might work in your community?
Alameda County Office of Dental Health
Urban / Suburban ∙ Dental and WIC both County-operated
Alameda County, located just east of the San Francisco Bay, is an urban and suburban county with over 1.5 million residents and 14 cities. As the most ethnically-diverse county in California, those implementing the program in Alameda County have had to pay special attention to many different sets of cultural concerns.
The Alameda County Office of Dental Health (ODH) is currently collaborating with two county-operated WIC centers, which served over 4,000 women and 13,000 infants and children in March 2011. The ODH will include a third site in the near future, and plans to add others in time. The ODH and the county WIC program have worked together for decades as two branches of the county’s Department of Public Health; this relationship allowed for much better cooperation in developing and administering this program.
A dental team consisting of one Registered Dental Hygienist (RDH) and one or two case managers visits each of the two WIC centers once per week, usually treating 12-20 participants per day. The schedule was devised to maximize the number of potential participants per visit. Participants in need of further treatment are referred by county case management staff to community clinics or private dentists. Some of these providers have contracts which allow them to bill the county for treatment of uninsured children.
Around three-quarters of participants receive dental benefits through Medicaid, and thanks to strong support from WIC staff in acquiring billing information, all of these participants can be successfully billed. The dental team is reimbursed for uninsured participants by Alameda County through its sponsored care program.
The ODH is able to sustain the program largely through grants, thanks in part to their efforts in publicizing the program and appealing to private and public funding sources. Its main objective, with regard to funding and sustainability, is to attain Federally Qualified Health Center (FQHC) status. This would allow dental staff to bill at a higher rate and cover the costs of non-paying participants, thus improving the odds of long-term sustainability.
Marketing and Outreach
Dental services are promoted through posters at WIC centers, face-to-face discussions with WIC staff, and appointments (and reminders) by county case management staff.
Caregiver education is done in two stages: first through a class taught by a WIC nutrition assistant, then through one-on-one guidance with the RDH during and/or after the visual assessment.
The class lesson plan has been revised several times. At first, preprinted lessons from First 5 and the Office of Dental Health were used; while these were comprehensive and contained good information, they were not effective lessons for this population. The class is now based on a PowerPoint presentation with ten key take-home messages, and counts as one of the caregivers’ required WIC nutritional education encounters. The classes are given two to three times per day in either English or Spanish, depending on the day.
The participants generally speak either Spanish (around 60%) or English (around 40%). The case managers that serve on the dental staff are bilingual and often translate for the dental hygienist. In addition to language needs, the Office of Dental Health organizes its dental team so it will represent the ethnicities and cultures of the participants it expects to serve. This has proved invaluable for dealing with health-related cultural concerns, as well as with subtle cultural differences that could easily be missed; for example, expectations of how health professionals should communicate with their participants.
The dental staff also provides a variety of materials including an assessment of findings, referral information, the First Smiles Healthy Teeth Begin at Birth pamphlet (contact the Center for Oral Health for more information), toothbrushes, dental floss, toothpaste, and the Dora the Explorer book titled Show Me Your Smile!: A Visit to the Dentist (see Section 6 for bibliographical information).
The dental team has found this book to be particularly helpful. Not only do they believe it to be the best children’s dental book available at the moment, but they have also found it to dramatically ease children’s anxiety about their dental visits.
The Office of Dental Health case management staff tracks visits, referrals, and referral follow-through with their Healthy Kids, Healthy Teeth database. WIC staff schedules screening appointments with the on-site dental staff and provides support for follow-up.
Humboldt County Dept. of Health and Human Services
Rural ∙ Community Health Outreach Worker
Humboldt County, located on the far-north coast of California, is a densely-wooded and mountainous rural county with approximately 130,000 residents. Between the county’s large size, rugged terrain, and lack of pediatric or low-income dental services, access to dental care can be very difficult.
The Humboldt County Department of Health and Human Services (HCDHHS) dental team is collaborating with three WIC centers in the area. Collaboration has gone quite smoothly, thanks in no small part to the project leader’s prior experience in working at the same WIC centers now involved in this program. The team accepts repeat visits for continued preventive care, and typically refers participants with signs of decay to a private dental center in the county (or to more advanced centers if severe decay is found).
The current model employs a team of one Public Health Nurse, one Community Health Outreach Worker (CHOW), and one office assistant; the team bills through a dentist affiliated with the HCDHHS. The team visits each of the three WIC centers twice per month, roughly three hours at a time. Unfortunately, due to the rural nature of the area, this typically yields only 3-10 participants per visit.
The new model, effective July 2011, will no longer use a public health nurse and will rely on the CHOW to perform visual assessments and fluoride varnish applications. The schedule will also be scaled back to one visit per WIC center per month, and the team will double-book every other appointment to mitigate time lost on participants who fail to attend their appointments (which are more significant here due to the low volume of participants). HCDHHS hopes this will allow the team to see participants more efficiently.
Approximately 90% of participants are covered by Medicaid dental benefits, and a significant majority has been successfully billed; it has been the dental team’s experience that almost all participants bring their Medicaid cards, so they have little difficulty acquiring billing information. A small percentage of participants is covered by Children’s Health Insurance Program (CHIP), but the majority of the remaining 10% is uninsured.
In addition to participant billing, the HCDHHS receives some money through state funds, local grants, and the Center for Oral Health.
Marketing and Outreach
Dental days are promoted through posters displayed at WIC, Head Start, and family resource centers, and face-to-face discussions with WIC counselors.
WIC centers in Humboldt County do not have enough participants present at any given time for classes to be feasible, so WIC education is done individually. In addition, the CHOW discusses topics like family dental history, brushing history, and current habits, then works through the goal sheet with the caregiver; under the current model the nurse does the assessment and anticipatory guidance, but when the new model is implemented this will all be done by the CHOW.
WIC and dental staff have not found motivational interviewing techniques or ephemera (aside from the goals worksheet) to be particularly effective with their participants, so they are not used.
Most of the participants are English-speaking, but some are primarily Spanish-speaking; they are scheduled on days when the HCDHHS interpreter is available.
The dental team refers participants to outside care and keeps records of children when they receive dental services at WIC, but does not have the resources to do any further case management.
Sole-Practitioner RDHAP, Pomona, Los Angeles County
Suburban ∙ RDHAP
The city of Pomona is the fifth largest city in Los Angeles County. It has a population of nearly 150,000, almost two-thirds of which are Latino. While this suburb has no shortage of low-income pediatric dental care options, awareness of and motivation to attain quality oral health care is lacking.
Debbie Hartman is a sole-practitioner Registered Dental Hygienist in Alternative Practice (RDHAP). Ms. Hartman, along with two assistants, makes weekly visits to two WIC centers in Pomona, each of which serves thousands of women and children per month. Her team typically treats 5-10 participants per five-hour visit.
Participants who require treatment for caries are referred to one of several venues; one of the local dental practices, the nearby dental school, or one of the two local children’s dental clinics. All of these establishments accept Medicaid.
However, despite the high availability of pediatric oral health care, it does not seem to be a priority and participants are often unaware of dental services for which they are eligible. Ms. Hartman has also found knowledge of proper oral health practices to be rare and caries in both in children and adults to be abundant.
There are several issues that make sustainability a challenge for this model. Perhaps the most critical is the small number of participants the team sees during each visit. Other major concerns include the low reimbursement rate for an RDHAP and the difficulty in billing participants with Medicaid managed care. Participants on managed care are often unwilling to provide their billing information for fear of losing benefits that could be used at a dental office. Ms. Hartman estimates that around 70-80% of her participants have Medicaid dental benefits, while around 20% are undocumented. Ms. Hartman’s team does not turn away any participants, but many of them are not billable due to managed care reimbursement restrictions or lack of billing information. Ms. Hartman is considering seeking additional funding to cover some of her non-paying participants.
Marketing and Outreach
Dental Days are announced by WIC staff during nutrition classes. Ms. Hartman also posts a sign and her schedule in each of the WIC centers she visits.
WIC staff does not participate in dental education, so it is provided entirely by the dental team. The lesson is done one-on-one between a caregiver and, usually, one of the assistants. It is based on the Preventing the Spread of Tooth Decay in Babies and Young Children flip-book (available through the Center for Oral Health), though Ms. Hartman has added additional content such as xylitol information, discussion of the pH change of saliva after eating, and instructions on brushing and flossing for older siblings.
The team also provides a variety of materials for participants to take home, including informational pamphlets on several oral health topics (also available in Spanish), stickers, toothbrushes, toothpaste, dental floss, mouth mirrors, and two-minute timers.
Approximately 90% of Ms. Hartman’s participants primarily speak Spanish. Ms. Hartman and her assistants are Latina and speak Spanish. Ms. Hartman has found this familiarity with her participants’ language and culture to be extremely helpful; it allows her and her team to more readily connect with them and anticipate potential issues.
Ms. Hartman uses the Center for Oral Health Healthy Teeth Toolkit to manage participant information. Aside from referrals to other dental services, her team does not provide case management services.
With just under 250,000 residents, San Luis Obispo County is a primarily rural county, best known as one of California’s largest wine-producing regions. Located in Paso Robles, the second-largest town in the county, La Clinica de Tolosa is a non-profit clinic that focuses on providing dental care for underserved children.
As a specialized pediatric dental clinic whose main objective is to provide care for the underserved, La Clinica de Tolosa brings a great deal of relevant experience to this program. Its employees are both familiar with the low-income demographic in their area and highly competent at providing dental care to young children.
The clinic’s dental team, consisting of one dentist and one dental assistant, provides care at one local WIC center (located next door to La Clinica de Tolosa) with a participant base of approximately 1,700 women and children per month. The team works at the center twice per month, and sees 10-15 participants at each three-to-four hour visit. Participants requiring further treatment are referred back to La Clinica de Tolosa the following month.
The major barriers to the sustainability of this program are the low volume of participants and the high cost of employing a dentist. However, La Clinica de Tolosa does report a high number of billable participants; over 95% of its participants have Medicaid-covered dental benefits, and around 80% of its participants are successfully billed. Aside from the Center for Oral Health grant, they do not have any other sources of funding for the program.
Marketing and Outreach
Dental services are promoted by WIC staff through face-to-face discussions, appointment scheduling, and by handing out Dental Days flyers.
Classes are usually not practical in a rural area such as San Luis Obispo County, so teaching is done one-on-one: first by the dental staff during the assessment, then by a WIC dietician afterward. The WIC portion counts as one of WIC’s required educational encounters, so participants have additional motivation to attend. As La Clinica de Tolosa specializes in providing pediatric dental care to this demographic, they are well-versed in educating caregivers about their children’s oral health.
Education consists primarily of a verbal discussion about goals and concerns identified in the caregiver questionnaire and the visual screening of the child. Handouts on brushing, toothpaste, diet, infant care, and other topics are provided, as well as age-appropriate toothbrushes, floss, and fluoride toothpaste.
While San Luis Obispo County as a whole is primarily white and English-speaking, around 65-75% of the participant families participating in this program speak Spanish as their primary language. La Clinica de Tolosa ensures that there is at least one Spanish-speaking member on the dental team to meet this need and provides questionnaires and educational materials in both English and Spanish.
Due to lack of resources, La Clinica de Tolosa does not currently provide case management services. WIC staff does assist participants in scheduling appointments at the clinic, however.
Sonoma County is a suburban and rural county, with a population of roughly 480,000. While this beautiful county has over 250 wineries and attracts more than seven million tourists per year, poverty is not uncommon and low-income dental services—particularly for children—are lacking.
The Community Action Partnership of Sonoma County (CAP Sonoma), a non-profit public health organization, is currently collaborating with two of the four WIC centers in Sonoma County. They will be expanding to a third WIC center soon, and hope to include the fourth in the future. In total, these four centers serve over 10,800 participants per month. Their dental team consists of a Registered Dental Hygienist in Alternative Practice (RDHAP), who performs most of the participant treatments; a Community Health Worker; and a dentist, who facilitates the program and provides medical orders when required for the RDHAP to continue providing services.
The team is on-site five times per month and sees between 30 and 60 participants per day (depending on the WIC center and the length of the visit). Between January and March in 2011, the team averaged 211 participants per month. The team treats all siblings up to age 8 if services are requested.
Participants requiring more than preventive care are often referred to a local dental clinic which, conveniently, has a mobile unit that visits WIC centers specifically to treat children. The Sonoma County Indian Health Project treats a number of Medicaid dental clients in addition to the native population, so some participants are referred there instead. For participants requiring general anesthesia for treatment, the team refers to either a nearby non-profit pediatric dental surgery center, or if they are covered by Kaiser Health Insurance, a local dentist contracted with Kaiser.
While 76% of participants have Medicaid-covered dental benefits, only two-thirds of these (48% of its total clientele) are actually billable. It is difficult to make the program sustainable with such a low number of paid claims, but CAP Sonoma has found additional sources of funding. These sources include grants, monetary donations from a local business and a local charity group, and dental supplies from the RDHAP participating in the program.
Marketing and Outreach
Dental Days are promoted through face-to-face discussions with WIC staff and word-of-mouth referrals from other participants. Due to the high need for these services in Sonoma County, additional marketing has not been needed.
The class, developed collaboratively by WIC and dental staff, is notable in that it satisfies the WIC requirements for a nutritional education class and therefore provides additional incentive for participants to attend. While WIC staff was originally trained by the dental team to use the Preventing the Spread of Tooth Decay in Babies and Young Children flip-book, the lesson was revised to more closely resemble other WIC classes. It now revolves around five key messages, displayed on a large chart in the front of the classroom. The WIC educator explains several examples of each, and holds up photos for the class to examine.
The dental team, whose members have experience with this population and age-group, provide anticipatory guidance during the visual assessment to reinforce topics covered in the class.
Approximately 75% of participants are Spanish-speaking, and illiteracy is also a concern. The community health worker handles both translation and assistance with forms for the illiterate, and the risk assessment and goal-setting worksheets have pictures to aid comprehension.
While most models for this program refer participants to a dental home outside of WIC, Sonoma County is notably lacking in suitable dental services for children in this age range and population. The dental team has therefore taken it upon themselves to become the dental home for their lower-risk participants (Class I and Class II) who require only preventive care. The team provides case management services including referrals to dental providers, help applying for insurance, and participant tracking. They also have a system in place through which WIC staff can reschedule participants for bi-annual visits.