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Case management can be key to helping high-risk children

North Dakota study shows dramatic increase in Head Start children with dental homes

July 01, 2020

By David Burger

 Dr. Brent Holman
Dr. Holman
Fargo, N.D. — An ADA-supported study by two North Dakota dental professionals showed that proactive dental case management facilitates referrals and appointment compliance, reduces reimbursement barriers, and reduces the need for more costly future treatment for high-risk low-income children by promoting the prevention of dental disease.

The study focused on Fargo-area Head Start programs, which provide services to about 350 children in the Fargo and the southeast North Dakota region. The study explored how best to utilize the services of a community dental health coordinator (CDHC) who could, with the help of licensed dentists, connect high caries-risk children to dental homes.

“The project demonstrated many benefits of active case management, including identifying high-risk children with extensive treatment needs early and getting them linked to specialized care,” said Dr. Brent L. Holman, past president of the North Dakota Dental Association and co-leader of the project.

“It also documented the process of case management interviews for Head Start families in developing trust and follow-through of treatment,” Dr. Holman continued. “It seems obvious that helping navigate financial, cultural, and preventive barriers for these families to get completed care would limit the eventual overall cost of treatment. Prevention pays.”

The ADA provided grant funding and both William Sherwin, executive director of the North Dakota Dental Association, and ADA staff were part of the early planning and provided support throughout the project, Dr. Holman said. The North Dakota Dental Assistants Association also supported the project.

Children in need


Dr. Holman defined case management as a collaborative process of assessment, planning, facilitation, care coordination, valuation and advocacy for options that have been shown to be a cost-effective tool to increase dental health.

 Ms. Marsha Krumm
Ms. Krumm
“Oral health is primarily supported by prevention, and when that prevention is connected to a dental home through case management, oral health is cost-effectively improved,” he said.

Before initiating the project, Dr. Holman, a pediatric dentist, and project co-leader Marsha Krumm, a dental assistant for Dr. Holman for nearly two decades before his 2014 retirement, CDHC and North Dakota Dental Assistant Association board member, knew that Dr. Holman and fellow pediatric dentists in the area had historically provided dental screenings for the Head Start children that did not have a dental home.

However, they witnessed time and time again the difficulty in getting treatment needs completed by the end of the school year, due to difficulty in locating dentists that would see Medicaid patients and lack of follow-through by families in making and keeping appointments. As a result, dental homes were few and far between.

The key to addressing the problem, Dr. Holman and Ms. Krumm, believed, was thorough and well-documented case management with the help of community dental health coordinators.

So they initiated a study to address the problem and assess the viability of their idea in a real-world situation.

The study provided for Ms. Krumm, a trained CDHC, to be connected to the Fargo area Head Start programs in the 2019-20 school year to provide screenings, caries risk assessment and identification of high-risk children.

The ADA launched the community dental health coordinator program in 2006 to provide community-based prevention, care coordination and patient navigation to connect people who typically do not receive care from a dentist in underserved rural, urban and Native American communities.

“The fact that a community dental health coordinator had professional connections to the dental community and understood the Medicaid reimbursement system for participating dentists, as well as the hospitals, greatly facilitated managing referrals and compliance with families and their interactions with providers,” Ms. Krumm said.

Dramatic upswing

The ultimate goal was to get these high-risk children linked to dental homes where needed treatment could be completed by the end of the school year, Dr. Holman said.

“These high-risk children were most at risk for extensive caries progression and eventual need for the most expensive treatment, which involves general anesthesia in a hospital setting,” he said. “Case management interviews were completed with families that could be contacted by phone. Additionally, efforts were made through case management to link the child and their family to education and prevention to minimize future caries risk. Outcomes were assessed at the end of the school year by follow-up with treating dentists and parents.”

The outcomes at the end of the 2019-20 school year were dramatic.

The number of Head Start children with accessible dental homes increased from 38% of enrolled children at the beginning of the year to 90% by the end of the year.

“There was no substitute for personal contact with caregivers, and through listening and follow-up, trust was established, and many parents demonstrated motivation to get treatment completed and improve prevention,” said Ms. Krumm.

Case management is worthwhile, the project leaders concluded, which suggests that more widespread adoption of the process could be warranted in other areas where it isn’t yet the norm.

Insurance questions

“There is no question that there are many more evidence-based models and experienced reimbursement systems in medicine than there are in dentistry, with examples being diabetes, asthma, behavioral health and cardiovascular disease,” Dr. Holman said. “Dental reimbursement has traditionally tracked procedures and treatments with less focus and innovation on population-based health outcomes and prevention. As a result, there has been resistance by third-party insurers to reimburse for dental case management.”

Therefore, the project also proposed a narrative for third-party documentation and reimbursement. Insurers, as well as the professionals providing case management, must develop a common language to assure the needed components of patient interaction and prevention were completed, Dr. Holman and Ms. Krumm said in their report.

“The reluctance for Medicaid and third-party insurers to reimburse case management is rooted in challenges in assuring integrity in billing and limited precedence nationally in establishing case management payment protocols and fees,” Ms. Krumm said. “Patient narratives to document case management activity are a logical way to help minimize program integrity concerns, while building a utilization data base.”

In the end, CDHCs providing education, prevention and case management strategies can be a model that works, Dr. Holman said.

“The interaction with referred dental offices by a case manager who was seen as a dental colleague greatly improved the connection to dental homes and the completion of treatment,” he said. “By focusing resources on those high-risk children, costly specialized care is reduced and families are connected to maximum prevention with a dental home.”