We report the results of a dental society–managed ABCD program. This evaluation builds on previous work, but examines a variant of the ABCD model in Yakima County, where the dental community assumes greater responsibility and leadership than elsewhere in the state. We hoped to find increased awareness of the dental needs of low-income children, positive feedback about the program’s impact in the community and strong support for the ABCD concept within the dental society.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Program setting. Yakima County, located in rural central Washington, has a population of more than 220,000. In 1999, the per capita income was $20,811, which was 72 percent of the state’s average.⁶ The population is 58 percent white, 36 percent Hispanic, four percent American Indian, one percent Asian and one percent African-American⁷; the county accounts for one-tenth of the state’s Medicaid population. One in three births in Yakima County is to undocumented alien parents whose primary language is Spanish.

ABCD program description. The Yakima Valley Dental Society, or YVDS, through its nonprofit foundation, the Central Washington Oral Health Foundation, or CWOHF, operates this program. It is responsible for recruiting eligible patients and assists with referrals. Consistent with the ABCD model, the University of Washington, Seattle, provides short-term training of participating dentists. Other partners include the state Medicaid agency and the Washington Dental Service Foundation, or WDSF.

Funding for this outreach effort is from a grant to the university from the WDSF, which is matched with Title XIX funds from the Medical Assistance Administration, Department of Social and Health Services of Washington state; the funds are then subcontracted to CWOHF. The university, as a governmental entity, has overall responsibility for the use of these funds. The dental society received a separate small grant from the WDSF to help it establish an office. Before 1999, the society had neither an office nor staff members. All dental fees are paid by the Medicaid agency and no dental services are grant supported.

The ABCD program emphasizes comprehensive preventive dental care in young children and encourages regular dental visits as soon as infants develop their first tooth. This variant of the ABCD program began in June 1999 and is called "Mom & Me" to emphasize the role of the mother.

Mom & Me program. Dentist participation in the program is encouraged through the YVDS. Dentists receive training to participate in the program and are certified to receive enhanced payments for their services through Medicaid. The one-day training session is provided by the University of Washington and covers topics such as dental examinations of infants and toddlers, behavioral aspects of treating children, fluoride varnish application and the use of fluoride-releasing glass ionomer restorations. The training includes both lectures and clinical demonstrations. Participating dentists receive quarterly update newsletters.

The one-day training session covers topics such as dental examinations of infants and toddlers, behavioral aspects of treating children, fluoride varnish application and the use of fluoride-releasing glass ionomer restorations.

The dental society and its foundation conduct outreach efforts. The program staff includes a full-time administrator, a full-time outreach manager and a part-time administrative assistant. The outreach manager and administrative assistant are bilingual.

All children in the Medicaid program from birth to 72 months old are eligible for enrollment.⁸ At the outset of the program, eligible children were enrolled in the community and through the dental offices, but after one year, recruitment efforts concentrated on health fairs, churches, Women’s Infant’s and Children’s Supplemental Nutrition Program orientations, prenatal classes and other parental education settings to increase participation. Home visits also are conducted for parents who are interested in the program but are unable to attend community presentations. About five group presentations and 20 home visits are conducted each week.

Media coverage about the program includes Spanish and English advertisements in local newspapers and stories on radio and television. Bilingual program staff members regularly contact enrollees by telephone to encourage making dental appointments and to update personal information such as phone numbers and addresses.

At the time of enrollment, the outreach staff works with the mother to match the child to a dentist. The mother is informed about how to make an appointment and the importance of keeping appointments. One week later, a staff member follows up by telephone. These follow-up calls were initiated in the second year of the program to encourage parents to participate and to answer questions. The Mom & Me staff members also make weekly rounds to the participating dental offices to keep informed about concerns the practices have and to help resolve any problems that patients may have.

ABCD program benefits. All routine dental services are available to enrolled children. Enrolled children also can receive enhanced dental services including three fluoride varnish treatments per year and atraumatic restorative treatment/glass ionomer fillings, as well as participate in two family oral health education sessions per year.

Survey format. Program staff members identified dentists who participated in Mom & Me and those who do not. Each dentist was sent an introductory letter and then contacted by telephone. Thirty-nine dentists who participated in the ABCD program and the 22 nonparticipating dentists in the county were contacted (one participating dentist later moved, so some data are based on 38 dentists). The Institutional Review Board of the University of Washington approved the study protocol and dentists’ consent was obtained.

A 22-item, 10-minute telephone survey was designed by the university for the study. The survey consisted of questions in four topic areas: awareness of dental needs in children, impact on dental practices, impact on the community at large and impact on the dental society. Included in the survey were multiple-choice questions and open-ended questions eliciting comments.

For each multiple-choice question, answers consisted of 3- to 5-point scales. For example, a question about awareness of dental needs in children provided answers on a 3-point scale in which 1 = very aware, 2 = somewhat aware and 3 = not aware. The answers consisted of "very," "somewhat" and "not" for 3-point scales; "very," "somewhat," "uncertain" and "not" or "serious," "moderate," "slight" and "not" for 4-point scales; and "greatly increased," "somewhat increased," "stayed the same," "somewhat decreased" and "greatly decreased" for a question on a 5-point scale. The means in both groups (participating and nonparticipating dentists) were calculated for comparison.

Response rate. The response rate was 61.5 percent (24 of 39) for participants and 63.6 percent (14 of 22) for nonparticipants. Among participants, one (2.6 percent) had retired, two (5.1 percent) refused to participate in the survey and 12 (31 percent) never responded despite multiple telephone calls. Among nonparticipants, two (9.1 percent) refused to participate in the survey and six (27.3 percent) did not respond to telephone calls.

All participating dentists surveyed were members of the local dental society; their mean age was 47 years (range, 30 through 71 years). Twelve (86 percent) of 14 nonparticipants were members of the dental society; their mean age was 51 years (range, 28 through 76 years). Among participating dentists responding to the survey, 21 (88 percent) had been involved in the Mom & Me program from the outset, one (4.2 percent) had been involved for about one year and two (8.3 percent) had been involved for less than one year.

Analysis of access data. Staff members obtained data from site visits to dental offices and from accounting records. The records contained expenditure information in regard to training dentists and community outreach efforts. The training costs included the cost of adapting the ABCD training course for dentists and their staff members, the cost of materials needed for courses and travel expenses for course faculty members. The outreach costs included the salaries of and benefits for outreach workers, as well as the cost of materials and local travel.

Statistical analysis. Staff members from the University of Washington entered the collected data into the computer and converted them into a statistical package (Statistical Package for the Social Sciences, Version 10.0 for Windows, SPSS Inc., Chicago). Descriptive analyses then were conducted.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Dentist participation. Fifty-nine general dentists and one pediatric specialist practice in Yakima County. Thirty-four (57.6 percent) of these general dentists and the pediatric dentist participate in the Mom & Me program. Four additional dentists from outside the county participate in the program, two traveling from western Washington regularly and two with practices in a town just outside the county. With the exception of the two dentists in western Washington, all participating dentists are members of the local dental society. Of the 38 participating general dentists, only 15 (39.5 percent) were treating children enrolled in Medicaid on a regular basis before the start of the Mom & Me program.

Patient enrollment. In the first quarter of the program, 725 children were enrolled; enrollment steadily increased by approximately 200 children per month to reach a total of 4,705 by the two-year mark (Figure), which surpassed the initial goal of 3,000 children. Between June 1999 and June 2001, 751 children exited the program as a result of age or having moved out of the area. As of June 30, 2001, 3,954 children were actively enrolled. After two years of operation, 2,388 children (51 percent) had had at least one dental appointment. The overall no-show rate across the 38 dental offices during the two-year period was 7.3 percent.

View larger version (29K): [in this window] [in a new window]   Figure. Actual vs. expected enrollment in the Mom & Me program operated by the Yakima Valley Dental Society and the Central Washington Oral Health Foundation in Yakima County, Wash., from June 15, 1999, through June 30, 2001.

Dentist participation. Since the inception of the Mom & Me program, more dentists in the county have been seeing Medicaid-eligible children. Six (25 percent) of 24 participating dental offices responding to the survey did not see Medicaid-eligible children before they participated in the program. The percentage of dentists surveyed who reported seeing Medicaid-eligible children daily increased from 29 to 42 percent (from seven dentists to 10 dentists) since the program began, and those reporting having seen children one to three times per week increased from 25 to 42 percent (from six dentists to 10 dentists).

Appropriateness of seeing younger children. Participating dentists, even those who were already treating Medicaid-eligible children before the Mom & Me program began, reported that they were now seeing younger children than before. Nineteen (79.2 percent) of 24 participating dentists surveyed believed it very appropriate for 1- to 2-year-old children to see a dentist, while only four (28.6 percent) of 14 nonparticipants responded similarly.

Since the inception of the Mom & Me program, more dentists in the county have been seeing Medicaid-eligible children.

Impact of program on the dental practice. Dentists who participated in the Mom & Me program generally provided positive feedback about the program. Eighteen (75 percent) of 24 participating dentists surveyed said they would recommend the program to other dentists. Eighteen participating dentists (75 percent) reported that the program somewhat or greatly improved the image of dentistry in the community. Participating dentists said that the no-show rate seemed to be lower among children enrolled in Mom & Me than among children from low-income families in their practices generally, and some offices reported that the rates were improving with time.

Impact of program on the dental society. Thirty-one (81.6 percent) of 38 dentists surveyed believed that the Mom & Me program was somewhat or very helpful in improving the image of the dental society. The dentists believed that by having a dental society associated with a community dental care program, the organization was expressing its concern for the dental needs of low-income children. They reported that having the backing of the dental society encouraged more dentists to open their doors to low-income children.

Impact of ABCD in the community. Nineteen (79 percent) of 24 participants and six (43 percent) of 14 nonparticipants reported that the program somewhat or greatly improved awareness of the need for dental care among parents in the community (mean score for participants on a 5-point scale = 2.1 vs. 2.7 for nonparticipants; t = 1.4; P = .2). Younger siblings also began coming to the dental office as parents realized that dental care could begin as soon as children developed teeth. Participants also reported that parents were helping to improve dental awareness in the community by passing information on to friends and encouraging other parents to adopt health-promoting behaviors.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The U.S. surgeon general’s report in 2000 highlighted the need to increase dental access for low-income people.^1,2 Nevertheless, few programs to address this persistent problem have been described or evaluated. This evaluation of the Mom & Me program in Yakima County, Wash., describes one model for improving dentist participation and increasing access to care.

Since implementation of the Mom & Me program, the number of dentists treating Medicaid-enrolled children on a regular basis has increased from 15 to 38, a 153 percent increase in the past two years. The survey elicited positive feedback from participating dentists. Having the program associated with the dental society led dentists to feel they were directly affecting children in the community, and doing so from a unique perspective provided by their professional experience. Nonparticipants also were aware of the program because it is managed by the dental society.

Mothers of children younger than age 72 months are receiving educational information about dental services through their participation in the program. Roughly half of the children actively enrolled have visited a dentist at least once during the two-year period (2,418 of 4,705 children). In addition, the overall no-show rate in the dental offices was low. However, the number of children being seen on an ongoing basis has been lower than anticipated.

Outreach efforts. The program hopes to increase the number of initial enrollments and recall visits through regular postcard mailings (in Spanish and English) to parents. A previous study conducted in Spokane County, Wash., found that parents did not use preventive services, in part because they were not aware of specific program benefits.¹⁰ Continuing medical education and outreach to primary care physicians is also being developed to increase referrals of the youngest children.

Cost per child. The cost per child for this outreach program, exclusive of dental care costs, was $32.22 in the first year and $54.34 in the second year (1999 dollars), which exceeded the cost of the health department–based program in Spokane. When converted to 1996 dollars (for comparison), the first-year costs per child were $27.38 for Yakima vs. $20.09 for Spokane. Second-year costs per child were $49.71 for Yakima vs. $18.77 for Spokane (also in 1996 dollars).¹¹ These differences exist because the administrative and overhead costs in Spokane County are not fully charged to the program and the Yakima program is more expensive relative to the actual number of children enrolled.

The Yakima program began making home visits and follow-up telephone calls to parents in 2001. These calls and visits are labor-intensive and increase the cost of the program. Such calls usually are not made in Spokane. However, the effectiveness of this extra effort has not yet been demonstrated. Staff members also make weekly dental office visits to check with dentists and their staff members, which is in excess of what is done in Spokane. This dental society–based model was chosen in large part because the local health department lacked experience in working with local dentists and was unable to make the type of substantial commitment required for an ABCD program to succeed as it did in Spokane.

Efforts are under way to develop a sustainability plan to allow the outreach program to continue after its initial three-year grant support is discontinued. The plan will allow for outreach personnel to perform preventive services such as fluoride varnish applications, family oral health instruction and limited visual oral assessments of enrolled children under the supervision of a licensed society member. Some of these activities require changes in the state’s dental practice act.

Participating dentists already have begun to provide local screenings twice a month throughout the county outside of their offices. These services are billed by the CWOHF to Medicaid, allowing the program to move toward financial sustainability. Nevertheless, increased cooperation with the local health district is highly desirable. This issue of sustainability is a potential problem in all of the ABCD sites where the local contribution to program funding is being underwritten on a short-term basis by WDSF. Ultimately, the communities themselves will need to contribute local tax dollars if these valuable programs are to continue.

The ABCD program, which started in Spokane County in 1995, is being implemented in Washington on a county-by-county basis. Unpublished analyses show increasing numbers of dentists participating, and utilization of services for very young children doubling in these counties (written communication, WDSF, Jan. 10, 2002). Similarly, at least one early study of this population suggests an improvement in oral health.¹² Thus, a dental society–managed program is beneficial in increasing dentist awareness and participation, as well as in addressing issues of dental access in low-income populations.

	CONCLUSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The ABCD concept is being modified and adopted in other states. ABCD programs in Washington have been initiated in which both the local dental society and an outreach agency have sought to work together, and where the majority of general dentists and pediatric dental specialists have agreed to participate.

Nevertheless, the long-term success of programs like ABCD depend largely on the quality and effectiveness of the outreach efforts and case management. The key is frequent contact with dental office staff members, a low no-show rate and a dentist-friendly Medicaid program. New and ongoing programs should be continually evaluated and improved. Ultimately, children from low-income families who see a dentist regularly should benefit by having better oral health habits and reduced oral disease.

View larger version (120K): [in this window] [in a new window]   Mr. Fuhriman is executive director, Yakima Valley Dental Society and Central Washington Oral Health Foundation, Yakima, Wash.

View larger version (134K): [in this window] [in a new window]   Dr. Milgrom is a professor, Department of Dental Public Health Sciences, and the director, Northwest/Alaska Center to Reduce Oral Health Disparity, University of Washington, Box 357475, Seattle, Wash. 98195-7475, e-mail "dfrc{at}u.washington.edu". Address reprint requests to Dr. Milgrom.