Transforming Community Health: Incorporating Social Determinants in a Dental Setting

March 2, 2023

Elly Steel, DMD, MPH, says she and her colleagues at Cabarrus Health Alliance can easily identify the factors in their patients’ lives that affect their health just by observing and listening.

Elly Steel, DMD, MPH
Elly Steel, MPH, DMD, is the dental 
director at Cabarrus Health Alliance

“I know which of my patients have difficulty with transportation because they either show up an hour early or an hour late for their appointments,” says Steel, the dental director of the public health authority in Cabarrus County, North Carolina. “Our patients tell us all the time, ‘At school, I can get chocolate milk for the same price as regular milk, so I’m going to get that chocolate milk.’”

She says providers at Cabarrus Health Alliance have been adding each patient’s social determinants of health (SDOH), like access to transportation and nutritious food, to their patients’ notes. But they were not tracking the patterns of all their patients’ information across the dental clinic.

Now they are, and they plan to put that invaluable data to use as part of their ongoing learning within the Community Oral Health Transformation (COrHT) Initiative.

Transforming Oral Health Care Delivery in North Carolina

COrHT, an initiative of CareQuest Institute, provides a framework for safety net dental clinics to implement medical-dental integration and value-based oral health care. The initiative also features a learning community that reimagines efficient, equitable oral health care and promotes the imminent shift toward value-based care in dentistry. CareQuest Institute’s Three Domain Framework — which focuses on 1) tele-prevention (teledentistry), 2) minimally invasive care (non-surgical treatment of disease), and 3) integration of oral health with overall health care — serves as the foundation for the learning.

The clinics also provide clinical, financial, and demographic data related to those domains to CareQuest Institute.

COrHT Initiative in North Carolina launched last year as a partnership between CareQuest Institute; the Blue Cross and Blue Shield of North Carolina Foundation; and the North Carolina Oral Health Collaborative (NCOHC), which is a program of the Foundation for Health Leadership & Innovation (FHLI).

Steve Cline, DDS, MPH, is the vice president for the NCOHC. He says the experience with the COrHT Initiative has been a positive one.

“We are so excited to be working with CareQuest Institute on this important learning initiative in North Carolina,” Cline says. “We have 14 progressive dental clinics [including 11 safety net clinics] across North Carolina exploring how to incorporate some of the newest dental office practices to improve the dental and overall health of their patients. The lessons we learn will inform the future of dental practice.”

Stephanie Clester, RDH, MS, clinical content and support specialist at CareQuest Institute, has been leading educational and community-building efforts in the state.

“The clinics who participate in the COrHT Initiative are oral health champions who are poised to help transform the oral health care delivery system,” says Clester. “The Three Domains provides the framework for teams to implement cost-effective, comprehensive, and integrated care while also preventing disease.”

Early data are showing improvements in the care the clinics are providing as they work to implement the Three Domain Framework with their patient populations. For example, four clinics completed 531 chronic screenings between October and December 2022. Also, application of silver diamine fluoride (SDF) — a brush-on treatment that can arrest tooth decay — have increased.

Implementing a Social Determinants of Health Screening Tool

In January, Cabarrus Health Alliance started using a SDOH screening tool from the North Carolina Department of Health and Human Services for dental patients. (It was already using the SDOH screening tool for medical patients.) The Cabarrus Health Alliance’s leadership team, which included Steel, believed the questionnaire would be a good way to screen many of the other patients, so they implemented the process agency-wide.

“We wanted to have a standardized SDOH screener for different programs, different departments, different clinical services,” Steel says.

SDOH screening tools identify the needs of patients and help medical professionals connect them to the resources they need. The tool asks questions such as, “Within the past 12 months, did you worry that your food would run out before you got money to buy more?” and “Within the past 12 months, has a lack of transportation kept you from medical appointments or from doing things needed for daily living?”

“There’s a lot of opportunity,” Steel adds, “to reach a lot of different people in the community.”

Because the data are so new, it’ll take a few more months before Cabarrus Health Alliance can analyze them. But Steel says she expects the data will tell important stories.

“That’s something I’m looking forward to seeing as the data progress,” Steel says. “Like, oh, in 2023, we were able to see that 60% of our patients say they have food insecurities, but now we are down to 40% of our patients. Maybe it’s something we did — an intervention — that might have made a difference.”

Moving Forward with COrHT

The COrHT Initiative has two phases. In this first phase, clinics like Cabarrus Health Alliance are participating in the learning community. It was during a learning community call that Steel shared Cabarrus Health Alliance’s wider adoption of the SDOH screening tool with the 10 other safety net dental clinics that are participating in COrHT.

“I really enjoy getting to know other clinics throughout the state, including ones that have different setups than us,” Steel says. “So as a local health department, I talk to other health departments. I don’t talk to a lot of Federally Qualified Health Centers. I don’t talk to a lot of private practices who do a lot of Medicaid or self-pay patients, and so having that community is fantastic. But also just learning from experts from other states.”

Steel says community health workers and patient navigators have also been a crucial part of the process.

“Having someone who has been trained on having the conversations with the patients and knowing how to get them to the resources has been invaluable,” Steel says.

In the second and final phase of the COrHT Initiative, NCOHC and CareQuest Institute will develop a comprehensive impact report, which will help safety net clinics sustain the work and influence long-term reform.

“We are now halfway into the COrHT Initiative in North Carolina, and the teams are hitting their strides to implement and reach goals to improve oral health outcomes for the communities they serve,” Clester says. “The work Dr. Steel and the Cabarrus Health Alliance team is doing is both innovative and inspirational!”

The COrHT Initiative in North Carolina runs through September, and Steel says she’s looking forward to sharing the outcomes.

“Just seeing the results of our changes that we’ve implemented is going to be the best and most exciting part,” Steel says. “I would hope with the outcomes of COrHT in a few months from now, we will be able to say, ‘Hey, this model that has been used in other states, like Oregon or Iowa, worked well for these 11 clinics that did it here in North Carolina. This is what we recommend.’”

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