Section 2: Dental Partnership Activities

Making Dental Partnerships Work

Dental Partnerships, as part of their funding requirements, must establish service agreements with community providers in order to bring dental care closer to clients. In turn, dental schools, which are the lead grantee, focus on provider training. They also tend to provide specialty dental care, which generally comprises a small proportion of the dental services provided under these efforts.

Partnerships vary considerably as they reflect the character of service systems in different communities. However, some features are fairly common:

• Memoranda of Agreement. Partnerships typically establish formal arrangements to foster effective communications among partners, outline responsibilities of various parties, and establish methods to help guide efficient delivery of HIV oral health services for clients. Memoranda of Agreement are the norm and help ensure that all parties are clear on their responsibilities. These agreements generally cover topics like program operations, planning and monitoring, and evaluation.
• Referral Networks. These systems handle such core activities as identifying agencies with HIV-positive clients that they can refer to dental services and tracking clients to ensure they received their services. In limited cases, like the Arizona project by Lutheran Medical Center, appointment-making is centralized among multiple agencies.
• Collaboration in Planning. Formalized cooperation occurs in some sites via planning bodies—particularly Ryan White groups. The Louisiana project is notable in that representation on the Governors Commission on HIV/AIDS was a forum for creating a new network of referral sources. This body was also the jumping off point for dental programs involvement in a Statewide quality improvement committee.
• Strategic Planning. New Jersey’s project is unique in having devoted attention to development of a long-range strategic response plan for expanding access to dental care. It covers such key areas as customers, financials, internal processes and learning and growth.
• Communications. Communications among partners is routine in terms of patient care and involves ongoing phone and email communications. Face-to-face meetings and problem-solving/case sessions are also used, although these are less frequent.
• Service Settings. A number of grantees have dental services co-located with other primary care services, such as those in Massachusetts, New York, California, Colorado, and Mississippi. Others, like the Illinois grantee, have dental care at separate but convenient sites. Regardless, mechanisms exist to facilitate seamless receipt of dental and primary care. Examples include well-designed referral and follow-up systems.
• Experts in HIV Dental Care. Dental school faculty often have staff positions within community agencies, reinforcing the educational experience for students and, additionally, bolstering the quality of dental care that patients receive.

Involving Consumers

While the Partnership is not prescriptive with respect to mechanisms to use for consumer involvement, all grantees are encouraged to develop appropriate methods, such as advisory board involvement, patient satisfaction surveys, and focus groups to solicit program input from consumers.

• Satisfaction Surveys. Loma Linda University actively involves consumers and implements satisfaction surveys and direct day-to day input to help shape the program and meet the clinical and psycho-social needs of the patients, and facilitates the educational experience of the students. Likewise, a dental site under the Mississippi project conducts random consumer satisfaction surveys.
• Consumer Advisory Boards. Oregon and New York City are among the few projects that use Consumer Advisory Boards. Columbia University in New York City works in partnership with Harlem United and sees the use of a consumer board as integral to the culture of the agency. Their board allows patients to share their feedback and experiences, such as sedation therapy, expanded hours of operations to include evening hours and Saturdays, and in-house oral surgery as ways to expand and improve HU dental care. The ability to create a family-like atmosphere and practice can be attributed, in part, to low staff turn-over and staff-consumer familiarity.
• Peer Advocates. Nova Southeastern University has, on average, four patients on staff as peer advocates for other patients. Their roles include providing patient information and education, making referrals, providing support and education about treatment adherence, and fostering retention in care. These peers also actively participate in the development of clinic activities including support groups, treatment updates for patients, and acting as resources for medical providers.

Provider Training/Student Learning

Dental projects have developed various community-based strategies to broaden the pool of dental professionals willing and ready to provide HIV care.

• On-Site Training. Rotations at clinic sites are common and vary considerably in their length. Among the longest is New Jersey’s University of Medicine and Dentistry of New Jersey, with a 9-month rotation of dental students. The shortest rotation is at Loma Linda University in California—two days training—although they incorporate small group discussions between a patient and a small number of students to help personalize treating patients living with HIV disease. Rotations range from a week to a month across other sites. New York City’s project at the Columbia University, College of Dental Medicine has a concentrated area of study requirement for all dental students, which several third year students opted to exercise in the Ryan White clinic setting where they served their rotations. One dental hygiene school in Oregon’s Partnership requires students to read an AIDS update newsletter and take a post-test prior to their rotation.
• Service Learning. One aspects of on-site training is service learning, which is a teaching approach that emphasizes community service within the dental education curriculum and bolstering that real-life experience within a student’s training. Several sites use service-learning experiences that include a reflection component to encourage critical analysis of trainings and the student role as a health professional. Observed the University of Illinois Chicago director: “This community-based service is a new style of dental education…. I feel that these service-learning rotations are a brilliant way to get students to think about their patients as people. They weren’t trained to treat people who were homeless or spoke a different language. It has opened the student’s eyes.” Illinois even uses a “Significant Moment Report” for students to write a short narrative about the impact of their training. Similarly, Oregon and Columbia University in New York City require students to keep a journal of their experiences.
  
  Nova Southeastern in Ft. Lauderdale uses a similar technique. Formal reflective time (i.e., time to brief, explore the learning experience and debrief) is built into the rotations in the form of daily “lunch and learn” sessions where the day’s cases are reviewed and analyzed. Medical, dental, social and behavioral profiles of the patients are analyzed, giving the students an opportunity to listen and learn from the on site behavioral scientists and social workers.
  
  Loma Linda convenes a small group of 5-6 students to engage in a one-on-one discussion with a volunteer patient. The session is prefaced by a one hour of didactic training and then a meeting with the patient for 30-45 minutes. Conversations are free form. Students typically ask whether patients have had difficulty getting good dental care, the effects of the disease and medications, and how patients want to be treated by their dental providers. Said one student: “I was a little nervous at the beginning but not anymore. I feel comfortable and really enjoy providing care to HIV patients.”
  
• Dental Hygienists. Sites typically focus training dental students and residents at their affiliated schools. Several—like Oregon and Mississippi—also target dental hygienists in order to expand the pool of dental professionals even more.
• Other Techniques. A small number of sites use other specialized learning methods. For example, Columbia University hosts a Web log site that allows students to share experiences as a community of learners. Columbia University also has a series of Dental Competency and Quality Assessment Tools to monitor students and their dental competency in key areas. One of these areas measures competency in delivering oral health care to PLWH.