Using Innovation to Improve Health
Innovation has always been at the heart of the Ryan White HIV/AIDS Program. With a level of collaboration that seldom occurs in health care system design, the program was created by activists; clinicians; people living with HIV/AIDS; providers; and Federal, State, and local government officials. In a breathtaking departure from many initiatives, the program reflected from the beginning that the epidemic in suburban New Jersey, for example, was different from the epidemic in Miami. A cookie-cutter solution would not work.
Local constituencies have used innovation and unprecedented means to address HIV/AIDS since the Health Resources and Services Administration (HRSA) launched its HIV/AIDS programs in the mid-1980s (see A Living History: The Ryan White HIV/AIDS Program). The first Ryan White legislation brought novel solutions in areas such as community planning, consumer involvement, and resource allocation. Perhaps the most important innovation was so intrinsic that it’s no longer regarded as innovative at all: the sheer breadth of ambulatory health care and essential support services provided through the legislation.
Innovation Creates Access
Dental care may not seem innovative in itself, but considering that approximately one-third of all Americans have no dental insurance at all, it demands an innovative approach to increase its availability and utilization.17,18 So perhaps it was indeed forward-thinking when in 1990 the Dental Reimbursement Program was made part of the Ryan White HIV/AIDS Program, in 2002 when the first Community-Based Dental Partnership Program (CBDPP) grants were awarded, and again in 2006 when oral health care was included as a “core medical service.” But the aim is not to be innovative for innovation’s sake; it is to create access to care for people living with HIV/AIDS.
The dental partnership program allows grantees like the University of Medicine and Dentistry of New Jersey (UMDNJ) to provide hands-on training for dental school students and residents in treating people living with HIV/AIDS in community-based settings. “The need for oral health professionals for HIV-positive people will only increase as consumers age,” says Jill York, D.D.S. She speaks from experience. In 2007, more than half of the HIV-positive people who received services at UMDNJ were between 45 and 64 years old.
“We were already seeing patients and training residents, but CBDPP funding made it possible to expand our community outreach. Since then we have grown dramatically,” says Dr. York. “We grew from nearly 300 patients in 2002 to more than 600 in 2007.” That kind of growth highlighted the need for more providers who understood the challenges of community-focused dental care. “In 2006–2007, we recruited 11 students from the dental school to train with us for a year,” says Dr. York. “Four of the 11 stayed on and have taken jobs with us, and 2 of the 4 are faculty members.”
One of those past students is Steven Toth, D.M.D., who graduated in 2007 and is now working in the program. “It feels good coming from my background with no HIV experience to now really being part of this program and giving back to the community.”
It’s this sense of social responsibility that Dr. York tries to instill
in students and that has driven her work since 1996, when an encounter with
a young schoolgirl changed her life. “I was doing screenings for Head Start,
and a 4-year-old girl came in with what looked like thrush, a common symptom
of HIV. The child had HIV and no one claimed to know,” Dr. York says.
SPECIAL PROJECTS OF NATIONAL SIGNIFICANCE PROGRAM: CURRENT INITIATIVES
- Improving linkages to HIV primary care and services in jail settings (2007–2011)
- Enhancement and evaluation of health information electronic network systems for PLWHA in underserved communities (2007–2011)
- Innovations in oral health care (2006–2010)
- Evaluation of innovative means to integrate buprenorphine opioid abuse treatment in HIV primary care (2004–2009)
- Outreach, care, and prevention to engage HIV seropositive young MSM of color (2004–2009)
See also The HIV/AIDS Program: Special Projects of National Significance (SPNS).
Connecting With Claire
The sun beams down on the Miami Dental Access Program (MDAP) mobile dental van parked at Jackson Memorial Hospital, and HIV-positive people are lining up to be seen. Dental care, like so many other health care services, is a luxury for the underinsured. But for uninsured patients like Claire, access to dental care is now a possibility, thanks to a Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS) grant.
Claire started using drugs in her teens. “Drugs controlled my life,” she says. Her drug abuse, coupled with her HIV-positive status, diagnosed during a stint in jail, threw her life into a tailspin.
“I lost connection with my family because I didn’t think they could accept that I was living with HIV.” At one point, Claire attempted suicide to end her isolation, addiction, pain, and shame. It has been a long battle, but she has been sober for 5 years. Part of her recovery has been getting care from MDAP for her teeth, which she neglected while using drugs and which had severely decayed. “Being able to have this dental care is like winning the lottery,” Claire says. “If you have rotten teeth you have a rotten life.”
Making Innovation Happen
The Part F SPNS program creates and evaluates innovative approaches to care for people living with HIV/AIDS. Throughout its history, the SPNS program has examined issues like access to care for African-Americans, women, youth, and residents along the U.S.–Mexico Border, and now it is examining access to oral health care. (See The HIV/AIDS Program: Ryan White Parts A - F.)
The MDAP is 1 of 15 SPNS Oral Health Initiative grantees in the country, and 1 of only 3 using a mobile van outfitted with dental equipment to expand the reach of care. MDAP grantees are the University of Miami Miller School of Medicine Department of Epidemiology and Public Health and the Jackson Memorial Hospital Division of Oral Surgery and General Dentistry. They took what had worked to engage and retain HIV-positive people in care and combined it with a new approach. The result was a mobile van like the ones used for HIV outreach but with a twist—a complete dental office capable of delivering oral health care services.
The Dental Access Program was conceived by principal investigator Lisa Metsch, Ph.D. The program was borne of the oral health linkages that Jackson Memorial Hospital had with three HIV/AIDS primary care clinics in Miami/Dade County that were unable to offer dental services. The team decided to use the van as one of the first transportable dental offices in the country, taking oral health services directly to people who needed them.
Today, patients can leave their primary care appointment at 1 of the 3 clinics and step aboard the van to get cleanings, oral exams, x-rays, and fillings. Those who need more extensive care are given referrals to complete their care.
Yves Jeanty, M.P.H., epidemiologist, is project director for the MDAP. He
explains that Jackson Memorial Hospital, a program partner, is a principal
provider of HIV/AIDS ambulatory care in the region. “Ninety percent of the
patients who get their clinical care here are doing so because of Ryan White
HIV/AIDS Program funds,” says Yves. He adds that the hospital has built trust
among the people it treats, but “even in a close-knit community like this,
people living with HIV/AIDS still face stigma because of their illness. We
use an innovative route to care by taking it to where people are.” This approach
appears to be working: 10,000 people have received dental care through the
clinics and the van. “Without the van, clients could wait up to 6 months
to get the services they needed,” Yves observes.
Creating New Connections
It’s been 24 years since Henry Boza got his HIV/AIDS diagnosis. “I got my test results from a person dressed in what looked like an astronaut suit. He came into the room, dropped the diagnosis on the table and said, ‘Go home and die like the rest of you.’
“I drove to the Golden Gate Bridge, in San Francisco, and got out of the car,” he recalls. “I was crying so hard that I couldn’t drive.” He says he never thought about ending his life, but he did think about all the people he had lost in the early years of the epidemic. “I felt like I had closed the eyes of everybody I loved.”
For Henry, that day proved to be cathartic. “There had to be a better way
for people to get their diagnosis. I decided that individuals weren’t going
to be treated like I was if I could help it.” Henry left San Francisco for
Miami, and it wasn’t long before he made good on his pledge. He began his
work in HIV first as a peer counselor and then by providing HIV counseling
and testing. He says that his experiences have helped inform the way he provides
health care support to clients. Today, he is project coordinator for MDAP.
Maria Blanco, D.D.S., is Henry’s colleague at MDAP. Her path to providing
HIV/AIDS services was that of a dental student—a different journey from Henry’s
but equally powerful and long lasting. As a University of Miami dental resident,
Dr. Blanco was the first dentist to provide care in the van in December 2007.
Dr. Blanco now works there 3 days a week, 1 day at each of the three clinic
sites the van visits. “The mobile van offers a good way to reach people,
especially ones who don’t know what services are available,” she says.
Dr. Blanco sees the van as a way to help patients be more proactive about their health. “We know that the cost of dental care and the fear of treatment are big challenges for people,” she says. She and Henry agree that the open, caring approach on the van helps clients get over their fears and seek out care. They have seen a big difference in patients and their outlook. “I remember a patient who had a bad smile,” says Dr. Blanco. “He always seemed sad. We did his dentures, which took about 3 or 4 months, but the day we delivered them he really smiled.” Dr. Blanco adds, “I feel I am doing something better than if I were in private practice. I enjoy coming to work knowing that I will change a patient’s life a little bit.”
Notes
- Centers for Disease Control and Prevention (CDC). Public health & aging: retention of natural teeth among older adults—United States, 2002. MMWR. 2003;52:1226-9. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5250a3.htm. Accessed April 4, 2008.
- U.S. Department of Health and Human Services (HHS).
Oral health in America: A report of the Surgeon General. Rockville, MD:
Author, 2000.