ࡱ> sur[ 5bjbj 6Jjji(: l  ppp8, 86($(LLLr8t8t8t8t8t8t8$); I=8 m8i X" @LL!8iii4b 8L Lr8ir8i"i36  .8L S p; 7J.8D808T7=hCA.8i b b Cambridge Public Health Department 119 Windsor Street ( Ground Level ( Cambridge, MA 02139 Cambridge Health Alliance 617.665.3800 ( Fax 617.665.3888 TO: Robert W. Healy, City Manager FROM: Harold Cox, Chief Public Health Officer DATE: June 16, 2004 SUBJECT: Council Order 0-9, dated 5/10/04, Re: Senior Dental Care  Senior Dental Care Overview  SHAPE \* MERGEFORMAT  Senior dental health is an emerging public health concern in the United States. The National Institute on Aging predicts that as members of the baby boom generation turn 65, they will swell the ranks of older Americans and pose a significant burden on geriatric health services, including senior dental services. In 2000, the Office of the U.S. Surgeon General issued a report called Oral Health in America. The report stated that while the extent and severity of dental health problems among seniors varied across subpopulations, many seniors had unmet treatment needs. The Surgeon Generals report cited research by Cambridge Health Alliance dentist Chet Douglass, which found that a growing number of older Americans were retaining their teeth longer, and that complete tooth loss had significantly declined among the nations seniors. Increased tooth survival has also created a greater need for senior dental care. Seniors who retain their teeth are exposed to the risk of dental disease, particularly periodontal (gum) disease and dental caries (cavities). Meanwhile, people with no teeth are at risk for oral diseases that affect the soft tissues of the mouth. Since 95% of oral cancers occur in adults over age 50, an annual screening for oral cancer is important for early detection.  SHAPE \* MERGEFORMAT Barriers to Access  Access to care refers to the presence or absence of various barriers to seeking or receiving health care. A barrier to access can be financial, physical, or cultural. In 2001, the Cambridge Homes Fund for Elder Care funded a survey to identify barriers to health care among frail seniors in Cambridge. The survey was conducted by Youville Hospital and Rehabilitation Center, in partnership with Concilio Hispano, the Haitian Coalition, and the Massachusetts Alliance of Portuguese Speakers (MAPS). It was completed in November 2002. The survey targeted specific Cambridge neighborhoods where it was expected that low income and language barriers might limit access to care. Of the 221 seniors who participated in the survey, 68 respondents were English-speakers, 64 were Creole-speakers, 53 were Spanish-speakers, and 22 were Portuguese-speakers. The overall income status of these seniors was low: 47% had annual incomes under $10,000. Among the respondents, 98% reported that they had access to health care. About 58% reported their health was good to excellent. Another 30% rated their health as fair. Melvyn Hecht, MD, the surveys principal investigator, wrote: The survey as presented shows us the unqualified success of the City of Cambridge to deliver health care services to the elderly population. The survey identified three key issues affecting the quality of life of frail elders in Cambridge: Dental care 44% of seniors reported that they did not have access to dental care. In addition, 41% of Portuguese-speaking respondents, 27% of Creole-speaking respondents, and 15% of English-speaking respondents cited that their activities were limited due in part to dental problems. Mental Health 36% of the seniors reported mental health issues, including depression. Lack of transportation 20% of seniors cited lack of transportation as a reason for not going out much. Frail elders in Cambridge, like many seniors nationwide, have traditionally faced some significant barriers to access to dental care. According to surveys conducted by Harvard School of Dental Medicine, the three biggest barriers to access to dental care among Cambridge seniors are: Lack of perceived need for dental care Many older adults do not seek dental services because they do not perceive a need for these services. In a 2000 study in Cambridge, far fewer elders perceived a need for care than the dental examiners who evaluated them. This was especially true among individuals without teeth. Lack of transportation Lack of access to transportation can diminish an older persons sense of autonomy and independence. It can also decrease access to dental services. In the Cambridge Homes survey, lack of transportation was cited as the top reason for not going out much by Portuguese-speaking respondents (68%) and Creole-speaking respondents (39%). However, only 3% of English-speaking respondents and 4% of Spanish-speaking respondents cited transportation as an issue. Financial constraints The ability of seniors to pay for dental care is another major obstacle to treatment. The majority of dental care provided to older Americans is paid for out-of-pocket. At retirement, few older adults retain dental insurance. In addition, Medicare and some Medicare HMOs (often used by seniors to supplement basic Medicare) do not cover dental services. In Massachusetts, only one of the three Medicare HMO plans available to Cambridge seniors provides any type of dental coverage. Blue Care 65, the Medicare+Choice plan offered by Blue Cross Blue Shield of Massachusetts, requires a $20 co-pay for dental office visits and covers oral exams, dental x-rays, and cleanings. The plan, however, does not cover any form of treatment (e.g., root canals). Harvard Pilgrims First Seniority Plan and Tufts Health Plans Secure Horizons do not offer any dental benefit. In March 2002, Massachusetts Medicaid program (known as MassHealth) eliminated coverage for all adult dental services, except teeth extractions. Improving Access to Dental Care for Cambridge Seniors  In 2003, the Cambridge Homes Fund for Elder Care awarded a two-year $95,000 grant to the Cambridge Health Alliance (in association with Harvard School of Dental Medicine) to increase access to dental care for frail elders in Cambridge. The goals of the Alliance project are to reduce barriers to achieving good oral health for elders by: Providing innovative ways for people to receive free cultural and language appropriate oral health education and preventive services in a community setting. Providing low cost and free restorative dental care in a variety of accessible clinical settings through the Cambridge Health Alliance and the dental education centers of Boston. Providing an elder care dental professional specialist to facilitate and manage access to care. This project, in conjunction with existing Alliance programs for seniors, is addressing barriers to senior dental care in the following ways: Outreach and education. The Cambridge Homes grant supports a part-time elder care oral health specialist in Cambridge who was hired in fall 2003. The oral health specialist meets with elders at the Cambridge Senior Center, the citys five assisted-living facilities, and other sites to discuss why dental care is important, even for people without teeth. In addition, she conducts on-site dental screenings where she provides voluntary fluoride varnishes to seniors with teeth. For seniors without teeth, she evaluates the stability, retention, and function of their dentures. The specialist also helps arrange dental appointments (primarily at the Windsor Street Dental Clinic) and transportation. Finally, the oral health specialist acts as a liaison between the Alliances Senior Health Connections, the Harvard Medical School Geriatric Program, and the dental program at Windsor Street. The Alliances Senior Health Connections is another venue for linking Cambridge seniors to dental care. Senior Health Connections is a free health information and resource service for seniors, caregivers, and providers. The telephone service is staffed by nurse and social worker who specialized in geriatric health issues. Services include general health care information, insurance information and assistance, and referrals to specialized health care services at the Alliance. Dental Services. The Alliances Windsor Street Dental Clinic (WSDC) receives the majority of the referrals from the oral health specialist. The clinic provides state-of-the-art oral health care services and advanced dental techniques. Interpreter services are available in Portuguese, Spanish, Haitian Creole, and Russian. Four general dentists and an oral surgeon, who have faculty appointments at the Harvard School of Dental Medicine, provide care at the clinic. Two dental hygienists also staff the clinic. The clinic has a formal affiliation with the Harvard School of Dental Medicine, and is the major clinical site of the dental component of the Harvard Medical School Geriatric Fellowship Program. On July 1, 2004, the Cambridge Health Alliance (in affiliation with Harvard School of Dental Medicine) will launch a new one-year residency program in general practice dentistry that will be based at The Cambridge Hospital. The residency program will focus on treating people with medical and other conditions that may affect their dental care. It is expected that residents will spend a significant portion of their time with senior dental patients. Also on July 1, the Windsor Street Dental Clinic will expand it hours for geriatric dentistry. Financial resources. The Alliance addresses the prohibitive cost of dental care in several ways: Free Care: Eligible seniors are enrolled in Free Care. Depending on their monthly income, these seniors may be eligible for full or partial Free Care coverage. Elder Service Plan: The Elder Service Plan is a comprehensive care program designed for frail elders who are nursing home eligible but wish to remain at home. Elder Service care includes free preventive, rehabilitative, curative and supportive care provided at home and at the Elder Service Plan office at 270 Greene Street in Cambridge. Dental services (as well as all other services) are provided on-site. Transportation is provided. Seniors pay no fees to participate in the plan. Other payment: The Windsor Street Dental Clinic accepts most insurance plans, MassHealth, offers sliding fees, and allows patients to make payments over time. PAGE 1 PAGE 4  U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.  U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.  A proposal to increase access to dental care for frail elders in Cambridge. Cambridge Health Alliance and Harvard Medical School Geriatric Fellowship Program. Submitted on May 6, 2003.  Report on a project to identify the needs of frail elders in Cambridge. Youville Hospital and Rehabilitation Center, Concilio Hispano, Haitian Coalition, and MAPS. January 2003. Funded by the Cambridge Homes Fund for Elder Care.  Ibid.  Ibid.  Dr. Michael Monopoli, Harvard School of Dental Medicine, personal communication, May 21, 2004.  Khanna A, Guyton B, Hayes C. Barriers to Accessing Dental Care in the Elderly Population of Cambridge. Thesis Project HSDM. April 2000.  Dental service use and dental insurance coverage-US, BRSS, 1996. MMWR 1997; 46(50): 1199-1203.  A proposal to increase access to dental care for frail elders in Cambridge. Cambridge Health Alliance and Harvard Medical School Geriatric Fellowship Program. Submitted on May 6, 2003.  Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, 2000.  Blue Care 65 customer service representative, personal communication, June 16, 2004. Also: Summary of Benefits 2004. Blue Care 65. Available at: www.bcbsma.com/common/en_US/pdfs/SOB_BC651003.pdf.  Summary of Benefits for First Seniority: March 1, 2004-December 31, 2004. Harvard Pilgrim Health Care; Tufts Health Plan Secure Horizons for Seniors: 2004 Partial List of Benefit Allowances and Member Cost Sharing Effective March 1, 2004 December 31, 2004. Tufts Health Plan. Available at: www.tufts-health.com/secure_horizons/pdf/2004_Indv_Rates.pdf.  A proposal to increase access to dental care for frail elders in Cambridge. Cambridge Health Alliance and Harvard Medical School Geriatric Fellowship Program. 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