EXPECTED OUTCOME by chenboying

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									RFI: MED-06-025 Dental Home for Medicaid Eligible Children Twelve Years of Age and Under
I. Name and principal address of vendor’s business: Dubuque Visiting Nurse Association 1454 Iowa Street, P. O. Box 359 Dubuque, Iowa 52004-0359 A. Organizational Background and Experience The Visiting Nurse Association, Dubuque has a long history of working within the community to evaluate and identify needs, developing action plans based on the needs assessment, and providing healthcare and dental services to meet those needs. The Dubuque VNA has been serving this community since 1910 and has worked with leaders in local government, education, and social service agencies to provide direct service to those in need when appropriate and to build community infrastructures that will assist in planning for long-range healthcare needs. Since beginning its affiliation with The Finley Hospital in 1996, the VNA has profited by being able to operate more efficiently with the ability to access Finley resources such as their finance departments to do billing and accounting. In addition, the VNA can now draw on the statewide resources of the Iowa Health Systems thus increasing the administrative talent available to the VNA. This makes the Dubuque VNA more able to accurately monitor and administer grants. B. Grant Management and Program Development Experience The VNA has experience in administering several grants for Dubuque County Board of Health and for the Iowa Department of Public Health including the Public Health Services Grant and the Maternal-Child Health Grant for the eight northeastern Iowa Counties. This experience includes financial oversight and timely reporting of funds used as well as reporting the progress made toward program goals and objectives. The VNA has a strong track record in program development including the School-based Dental Sealant Program and the VNA Adult Dental Clinic. The VNA Oral Health Services Program has consistently been a leader in the state demonstrating efficient and appropriate methods to provide dental service. This includes reducing barriers for families to access dental care through care coordination activities and promoting preventive dental care through education and early access through dental screening. . The VNA staff has demonstrated expertise in providing case management services. The present caseload volume for the Child Health Program alone is 869 children. This demonstrates that the VNA staff has the ability to assess client requests and determine eligibility for accessing these funds. VNA Mission Statement: The Visiting Nurse Association exists to promote and improve the health of the people and communities of Dubuque County through the provision of effective home and community-based services.

Vision Statement: The Visiting Nurse Association is dedicated to improving health through collaborative assessment, planning, and delivery of services with community partners. As a leader in public health and homecare services, the Visiting Nurse Association provides the highest quality of services in a climate of limited resources. We recognize our employees as our greatest asset. Adopted by the VNA Board 12/17/2002; Reviewed February 15, 2005 C. VNA Leadership/Staff Resources and Experience: Nan Colin, RN, BSN, MBA, VNA Executive Director, has thirty-four years of healthcare experience that includes fifteen years working in managerial roles serving the patients in acute and long-term care. Ms. Colin has been VNA director for three years so is experienced in administering grants and supervising program operations. Jacquie Roseliep, RDH, BS has worked for the Dubuque VNA for twenty-two years coordinating the oral health programs and providing dental services to the low and moderate-income families in Dubuque County. Patricia Kemp, RDH is a staff dental hygienist for the VNA working primarily with the Hillcrest/WIC Program, screening clients for needs and helping them access the system. Additionally she works in the School-based Dental Sealant Program. Laura Clemen, RDH, BS is a dental hygienist for the VNA working with the preschool screening program. She also has experience in working with elderly home-based clients and in private practice for a dentist who accepts Medicaid clients. Molly Schulte, LBSW has worked with the VNA for eleven years as the EPSDT Care for Kids Program Coordinator, educating Medicaid families regarding the importance of preventive care, and providing care coordination and advocacy to help them obtain necessary periodic EPSDT services. She also serves as Child Health Coordinator and provides leadership to EPSDT and Child Health staff in Northeast Iowa. Stacey Killian, BA has worked at the VNA for five years. She has experience in screening both adults and children to identify client needs and community resources available to meet those needs. EXPECTED OUTCOME The goal is for all Medicaid children 12 years of age and under to receive age appropriate dental care by having an established dental home for each child. The dental home should provide each of the components identified in the AAPD Policy Statement of a dental home. II. NECESSARY SERVICES TO ACHIEVE THE EXPECTED OUTCOME A. Education, Screening, Referral and Case Management Services 1. The VNA already provides case management service for Medicaid and Child Health clients. To provide service to the greatly increased volume, the VNA would need to increase staff capacity for dedicated dental case management and data entry.

2. All VNA case managers including social workers, nurses and hygienists will dialogue at monthly intervals regarding progress toward expected outcome and goal. 3. Client populations for focused Medicaid case management will include all screened groups (WIC, Head Start, pre-kindergarteners, kindergartners and 5th graders), Child Health clients, sealant participants and additional Medicaid children as identified. 4. Completion of the annual dental office survey to determine dental providers willing to serve Medicaid clients and distribution of the survey to agency case managers, Medicaid clients, agencies, schools and other interested parties. 5. Information Systems: Hardware (computer) is available for dedicated oral health case management. 6. Education resources for parents: A new education sheet is developed for informing Medicaid clients on the dental benefit, to include general oral health information, participating dentists, dental etiquette and dental home concept. This sheet can be modified to be appropriate for all screened populations (WIC, pre-kindergarten, Head Start), sealant participants, and other populations (child care nurse consultant outreach, health fairs, round-ups, school nurses, etc). 7. Education for Providers: A Dubuque County Medicaid Provider Summit for dentists who currently accept Medicaid and other interested providers will be convened by the VNA in conjunction with Healthy Mouths/Healthy Children. Discussion will include mutual goals, the concept of a dental home and case management basics. A plan for how the Medicaid client referral process can be better managed will be developed around identified obstacles. 9. Education of Dubuque County hygienists and assistants and other interested individuals (nurses, nurse practitioners) as to what is ageappropriate anticipatory guidance in relation to oral health will be offered by the VNA. Included will be the concept of a dental home, screening methodology, fluoride varnish application and case management. 10. Expansion of School-based Dental Sealant Program: With Dubuque Community School authorization, expand current screening program to include all pre-kindergartners and fifth graders, and the sealant program to include all seventh graders.

B. Information Systems Needs to Facilitate Service Provision: 1. CAReS: develop capacity to collect last dental date information and to query children without a dental home and/or overdue for dental visit by name and county of residence. 2. Paradox: If this system remains viable, assure that it contains up to date last visit information. 3. Expanded CMS416: develop capacity to report by name and by county the children without dental home and/or who are overdue for a dental visit.

Include paid claims for hawk-i covered clients. (Current reports give numbers and percents only). 4. Creation of New Agency Database: By child name, capture those who are screened, have suspected caries or other concerns, have dentist exams and have completed all needed dental care. Each activity and all screening/exam findings would be coded into this system so query demonstrates those needing services and those who have received these services. This information would be available to both dental and medical providers. The expected outcome would be efficient use of case management time; children requiring referral assistance receive it; and enhanced tracking system for all approved users.

C. Systems Capacity Changes to Implement Plan: 1. The Department of Human Services, Medicaid Enterprise, in conjunction with the Iowa Department of Public Health, Oral Health Bureau provides information to medical and dental providers (including dental hygienists, assistants, nurses, nurse practitioners, physicians, clinics, etc.) explaining the rationale of the mandate, the established timeline, the dental home concept, and offering local or regional contacts (i.e. public agencies, Maternal and Child Health agencies, and EPSDT program managers) to assist them in assuring compliance with the mandate. 2. The above group spearheads a statewide educational campaign on dental home concept and general value of oral health, which local agencies can build upon. 3. Legislatively, an increased level of reimbursement to dentists for Medicaid client services and a possible mandate for all dentists to accept a percentage of Medicaid clients into their practices are addressed. 4. The State Dental Board recognizes the value of public health dental hygienists in collaborating with local dentists to expand dental capacity. Administrative rules for licensure will allow dental hygienist expanded ability to practice independently under the supervision of a dentist. 5. The Dubuque County Board of Health formally recognizes the legislative mandate. 6. The Dubuque Tri-State Community Health Center will begin providing oral health services to all populations, including Medicaid.

III. HOW THE VNA WOULD PARTNER FOR EDUCATION, REFERRAL, AND PREVENTIVE SERVICES A. Educational/Informational:  EPSDT is a program within the VNA. Dental visit periodicity, a current listing of providers and dental office etiquette is information that is distributed through the VNA. In addition to newly informing information, the content of this communication could be targeted relative to age and to specific need (i.e. oneyear-olds and those with no dental home).

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Educational materials and staff inservices could be offered to medical offices providing prenatal care, hospital birthing units, mom/baby home visitor programs, and physician offices seeing the pediatric population. A Medicaid provider summit could be held to define population they will serve, AAPD definition of a dental home, how the VNA dental case manager(s) might assist them, and develop a system the providers would be comfortable using to assure client numbers and ages meet their guidelines. A mailing to all dental offices that accept any Medicaid clients (using agency phone-survey results) to further define mandate and requirements of a dental home as defined by AAPD would be done. The services of the VNA case managers would be included with contact information. An inservice for dental professionals (hygienists, assistants, receptionists and dentists) on age-appropriate anticipatory guidance would be offered. The intent would be to increase the comfort level of the practitioners and auxiliaries in dealing with the very young. Screening services and the School Based Sealant Program would be offered to additional grades within the school system.

B. Facilitating Dental Referrals:  A written dental referral originating from the pediatric physician office to the child’s dentist of choice would be piloted. (Emphasizes the importance of the recommendation).  For all children screened, the written findings would be sent home, along with age-relative oral health information and recommendations. Case manager contact information would be included. This data would be entered into the available data collection system for tracking purposes. C. Preventive/Screening:  Meet with health services coordinator of Dubuque Schools re: enhancing the current screening program for kindergartners, the feasibility of screening fifth graders city-wide, and the possibility of expanding the School Based Sealant Program to seventh graders at all public middle schools.

IV. HOW EACH SUGGESTED SERVICE WILL FULFILL OR PROVIDE PROGRESS TOWARD THE EXPECTED OUTCOME. A. The Goals of Education, Screening, Referral and Case Management are:  To improve oral health and reduce the incidence of decay across the Medicaid population through the implementation of daily oral hygiene and establishment of a dental home.  To establish mutual oral health goals for all professionals working with the Medicaid clients.  To increase completed dentist visits at appropriate ages to dentist providers, to begin 6 months from the eruption of the first or at one year of age. (Early entry into dental provider network)

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To increase knowledge of oral health practices and preventive techniques among the non-dental professionals. To increase the comfort level of those professional and paraprofessionals providing direct client services which may include education, screening and fluoride varnish application. To assure an adequate dentist provider network is available to provide needed services to identified population. By increasing the number of children to whom direct screening services (all prekindergartners and fifth grade) and examinations (seventh grade) are provided, the opportunity to identify more Medicaid children and educate the parent/guardian regarding the need for routine care and/or emergent oral needs increases. It also allows for targeted case management of children identified with oral health needs to assure the presence of a dental home and the completion of treatment. An increased level of reimbursement to dentists would demonstrate to the dental providers an increased value of the service they are providing and possibly assist in maintaining the provider pool. Information systems: Case managers working directly in the program have access to the critical information needed to assist the children in completing their needed care.

B. Information systems:  Targeted case management is efficient use of staff time. When children on Medicaid are identified by oral need (no dental home, not up to date with dental office visits, unmet dental needs and/or turning one year of age) activities can be tailored to meet that need.  Enhancing CAReS, Paradox, CMS416, and/or developing a new database allows for case management activities to occur in an efficient manner. Additionally, if children’s progress through the “dental process” (from identification to diagnosis, treatment initiation and treatment completion) can be tracked by a case manager or provider through the use of one of the above data systems, when client progress breaks down, efforts to assist the parent/guardian can occur.

C. Systems capacity: A united front across all health professions who this mandate will impact is critical. The efforts of local agencies to date in attaining the expected outcome have resulted in mediocre success. To obtain the desired result, the message of the Iowa legislative mandate must be consistent, strong and clear in order to be heard and acted upon by all intended audiences. The dental home concept remains elusive unless concerted efforts are made to literally open the doors to the Medicaid population in need of care. A requirement that all dentists accept a percentage of Medicaid clients coupled with an increased level of reimbursement for doing so would assist this effort greatly. As an alternative source of care delivery, the Dubuque Tri-State Community Health Center could assure a dental home to this client population.

V. CLEAR SUGGESTIONS/UNDERSTANDABLE WAYS THE VNA CAN SHOW PROGRESS TOWARD THE FULFILLMENT OF EXPECTED OUTCOMES, INCLUDING TIME FRAMES. 1. 100% of Medicaid children will have a dental home by July 1, 2008 as evidenced by having received one or more preventive services at that location or through the local public health oral health staff. 2. 50% of the Medicaid children with identified dental needs will have completed their regimen of care by July 1, 2008. 3. By October 1, 2006 the new or enhanced VNA data system will provide for the collection and report of critical oral health information needed for case management. The data system will allow for tracking of children in need of dental care as identified at any screening site and provider office. This system may be a pilot for a workable State data system. 4. By October 1, 2006 oral health educational materials specific to age and audience will be developed by VNA staff and distributed to all Medicaid families served by the VNA and to local medical and dental providers. 5. The number of Medicaid children who receive a screening in a non-office setting will increase by 30%. 6. The number of dental offices who agree to accept Medicaid children will remain stable. 7. The number of children who are seen in a dental office at one year of age will increase by 25%.

VI. THE ANTICIPATED TOTAL COST FOR ALL SERVICES AND A DESCRIPTION OF THE ELEMENTS INCLUDED IN THE COST ESTIMATE Projected Budget for Expanded Services for Year One Category Amount Salary-Additional RDH at 0.8 FTE $37,124 Benefits for 0.8 FTE RDH at 23% rate $8,538 A. Total Salary/Benefits for RDH 0.8FTE $45,663 B. Information Systems $3,000 th C. Costs to screen all 5 graders Dbq. Co. $6,354 D. Two additional school-based sealant clinics $3,227 E. Inservice Education Costs $937 F. Costs for Development of Education $3,140 Materials

G. Printing/Photocopying H. Postage Total Projected Expenses for Program Expansion for One Year Projected Revenue for Medicaid fee-forservice provided in expanded program Net Loss with Expanded Program

$1,200 $2,500 $66,021 $22,773 $43,248

Budget Narrative: A. Salary costs for staff dental hygienist at 0.8 FTE: $37,124 at projected rate of $22.31 for FY2008 Benefit costs for the staff dental hygienist at 23% rate: $8,538 Total staff cost for 0.8 FTE hygienist =$45,663 B. Information Systems costs for computer and support for one year: $3,000 C. Costs to Screen all 5th grade students in Dubuque County: Total costs=$6,354  150 hrs staff time including fringe: $5,584  $770 for supplies and educational materials including expense to provide each student with a toothbrush, the cost of latex-free gloves for each screening, and educational brochures. D. Costs of two additional school-based sealant clinics: $3,227 (includes staff time, supply costs). E. Inservice Education Costs: $935 (includes 20 hours of oral health coordinator time with fringe and $150 for materials and travel). F. Costs for Education Materials Development: $3,140 (includes 80 hours of oral health coordinator’s time with fringe). G. Printing Costs for Educational Materials: $1,200 H. Postage Costs: $1,800 for oral health informing and care coordination mailings. Projected Program Revenues through Medicaid fee-for-service (includes informing, care coordination, and oral health services such as initial and periodic screening, fluoride varnish applications, sealant applications=$22,773 Unacceptable Net Loss=$43,248. This projected net loss is unacceptable for the VNA in Dubuque. If the program is not self- sustaining, the VNA can not participate. The State will need to look at additional financial resources to support the program expansion. Since the VNA in Dubuque already has the various components of the program in place and has efficiencies piloted and ready to expand for this program, it is safe to assume that other MCH agencies would incur a similar net loss unless the State was willing to provide operational funds or enhance Medicaid reimbursement for services.

VII. VENDOR REPRESENTATIVE CONTACT INFORMATION: Nan Colin, Executive Director Visiting Nurse Association 1454 Iowa Street P. O. Box 359 Dubuque, Iowa 52004-0359 Phone: (563) 556-6200 Fax: (563) 556-4371 Email: Nan.colin@Finleyhospital.org


								
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