Problem Addressed

• Many children affected: Tooth decay, one of the most common childhood conditions, is five times more common than asthma and seven times more common than hay fever. More than half of children between the ages of 5 and 9 have had at least one cavity, while 78 percent of all 17-year-olds have experienced tooth decay.¹ In Colorado, 18 percent of 2- to 4-year-olds have dental caries, while 16 percent have untreated decay.²
• More common among low-income and uninsured families: Children living in poverty suffer from twice as much tooth decay as do other children, and their cavities are more likely to go untreated. Uninsured children are 2.5 times less likely to receive dental care than are children from families with medical insurance.¹
• Access to care a significant barrier: Although more than 20 million children receive coverage through Medicaid,³ many dentists do not accept public health insurance, leaving many low-income children without adequate access to dental care. In fact, up to two-thirds of children with public health coverage have not visited a dentist in the past year.⁴ In addition, children in rural areas often lack access to dentists, with primary care physicians often their only regular source of health care in the area. Although Colorado is 1 of 40 states that allow general physicians to bill Medicaid for oral examinations and fluoride applications for children up to age 5, many doctors and other health professionals in the state lack the training and education needed to provide such care.

Description of the Innovative Activity

• Training sessions for health care providers: Cavity Free at Three provides approximately 50 half-day training sessions each year for health care professionals across Colorado, including family doctors, pediatricians, nurses, physician assistants, public health practitioners, dentists, dental hygienists, and others. Since its inception, the program has trained more than 2,400 health professionals through 150 sessions (updated April 2013). A technical assistance team comprised of 97 medical and dental professionals statewide conduct the sessions (see the Planning and Development section for more information), which are held at various public sites. Individual providers, practices, or community organizations can apply to host a session, which is open to all health care professionals in the community. The program gives priority to safety net and public health clinics that wish to host a training. Continuing education credits are available for professionals who attend these training sessions. The sessions, provided free of charge, include the following core components:
  • Didactic education: The first half of each session consists of didactic education on a variety of topics related to the oral health of children, including: the causes, prevention, and prevalence of tooth decay; how to incorporate an oral health risk assessment into well-child doctor visits or other routine medical care; how to use motivational interviewing to encourage oral health behavioral modification in patients and other primary caregivers; and the importance of reaching out to caregivers and pregnant women about proper oral health care for their children.
  • Hands-on component: The second half consists of a hands-on demonstration of a fluoride varnish application. Participants are asked to recruit a few patients to attend this part of the session; these patients receive a free application conducted by the medical and dental professionals leading the session. Participants closely observe and participate in the demonstration as part of small groups.
  • Certification to receive Medicaid reimbursement: After completing both portions of the training, medical providers receive paperwork that certifies them to receive reimbursement from Medicaid for oral examinations and fluoride applications performed on children up to age 5.
• Take-home materials and resources for patients: Those attending the training sessions receive reproducible copies of a variety of patient education brochures, along with instructions on how to download additional free copies if needed. They also receive fluoride varnish kits, each containing a single dose of fluoride varnish, a toothbrush, and information cards on oral care for children. The program also connects participants to partnering vendor and vocational assistance program Bayaud Enterprises, where they can purchase additional kits at a reduced fee.
• Followup and technical support: Program staff provide ongoing technical support and assistance to all providers who have completed a training session. The program sends a mailing to each participant 30 days after the session, asking if they need support in overcoming any obstacles to implementation they may be experiencing. If so, program staff work with the provider, either over the phone or in person, to come up with possible solutions. Following trainings, participating providers are surveyed at 6 and 12 month intervals to inquire about their satisfaction with the program, program success, and any barriers to implementation (updated April 2013). This information is provided to the program director to guide improvement efforts. 
• Training for health care students: Cavity Free at Three has incorporated its model into the curriculum for health care students at the University of Colorado at Denver's Schools of Medicine and Dental Medicine, including students of multidisciplinary health disciplines such as doctors, physician assistants, nursing students, dental technicians, and more. In particular, students participating in the School of Medicine's Rural Track Program all receive Cavity Free at Three training. Training these students, all of whom aim to practice medicine in rural areas of Colorado, provides a prime opportunity to spread the provision of oral care services to rural children (who traditionally have limited access to dental care) in nontraditional primary care settings.

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Innovator Disclosures

Results

• Enhanced access to services: Since program inception in 2008, health care professionals trained through the program have provided more than 50,000 children and families with oral health education, screenings, and fluoride varnish applications (updated April 2013). In the absence of the program, it is unlikely that these children would have had access to these services, because most of those served had never seen a dentist (due primarily to a lack of private insurance).
• Satisfied providers and patients: Providers consistently report that the training increased their knowledge of children's oral health concerns and better prepared them to provide oral care education and services to patients. Anecdotally, providers report that patients and their families appreciate the potential to receive services outside of the routine dental setting, particularly those in rural locations.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Assembling team to design program, lead training: The program recruited a team of nine medical and dental professionals known for being committed community-based providers and/or health professional educators and researchers. This technical assistance team (which consisted of physicians, dentists, public health practitioners, a pediatrician, and a pediatric dentist) developed the program, and individual team members initially led the training sessions. Following several "train the trainer" sessions, the original technical assistance team has expanded to include 97 members capable of conducting trainings statewide.
• Designing training and educational materials: The team met regularly over a 9-month period to plan and develop program materials, including provider and patient education brochures and the training curriculum.
• Recruiting participants: The program initially recruited participants through targeted mailings to potentially interested organizations and previous grantees with a connection to oral health. During the program's second year, program leaders gave multiple presentations at state organization meetings and submitted articles in professional journals, all of which led to an increased interest in the program. Currently, word of mouth from satisfied participants creates a consistent queue of people interested in receiving Cavity Free at Three training.

Resources Used and Skills Needed

• Staffing: The program employs a full-time director, a full-time education coordinator, and a full-time program coordinator. The program also compensates members of its technical assistance team for each training session they conduct.
• Costs: Cavity Free at Three operates on an annual budget of $300,000.

Funding Sources

Getting Started with This Innovation

• Build multidisciplinary alliance: Bring together a multidisciplinary group of medical and dental professionals committed to improving oral health outcomes in children to brainstorm ideas on how to improve access to services.
• Establish public presence in medical field: Present the program at meetings and conferences designed for medical professionals. Physicians and pediatricians often want to get involved in oral health education and services, but do not know how to do so.
• Seek multiple funding sources: Having multiple, well-known donors signifies broad community support, which in turn attracts more funders.

Sustaining This Innovation

• Show providers monetary value of participating: Physicians will be more likely to continue their participation in the program if doing so is cost-effective. For example, with the Cavity Free at Three program, providers can buy a fluoride varnish kit for $6, and then receive an average $45 reimbursement from Medicaid for providing the service, thus providing them reasonable compensation for the time involved in doing so.

Use By Other Organizations

• Cavity Free at Three has been implemented at Women, Infants and Children (WIC) locations throughout the state of Colorado. WIC is a statewide program offering nutritional support to women and children.
• Colorado Children's Healthcare Access Program providers have adopted the Cavity Free at Three model as well. This statewide network of physicians uses Cavity Free at Three as a quality improvement measure.