How Seattle's Swedish Medical Center is linking dentists, clinics to improve population health

For Medicaid or uninsured patients who require complex dental surgeries, seeking care can be a daunting journey of clinic hopping when many health centers are ill-equipped to offer that level of service -- and the clinics that can are financially out of reach.

Eventually, the pain often lands these patients in hospital emergency rooms, which also may not have the facilities to deal with the overall dental care they need. Instead, they are sent off with pain medications, antibiotics and referrals back to community health centers.

It's a problem experienced around the country -- but in some areas, health centers and emergency departments are experimenting with a variety of programs that aim to divert patients with dental complaints into specialty clinics.

"Dental access has been so limited and care has been episodic for so many people or not at all," said Sarah Vander Beek, chief dental officer of Neighborcare Health, a network of health centers in Seattle. In 2015, the clinic employed about 20 dentists who saw 60,545 patients. "It just created a lot of people who have end-stage disease for their teeth with no other options but to have multiple or all of their teeth removed."

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In Washington's King County, which includes Seattle, dentists from health centers voiced their frustrations about the gap in dental care to the local dental society. To address the problem, the society in 2011 established a pilot project that connects Swedish Medical Center, a large nonprofit health care provider in Seattle; its dental residents, or dentists who have finished school but are in training; oral surgeons and health centers in the county in a streamlined system of referrals that will see any Medicaid and uninsured patients.

Here's how it works: Patients with non-life-threatening dental emergencies who visit the hospital's emergency department will be referred to a Neighborcare Health center. The health center will perform checkups, provide dental care and serve as a "home" for the patient. Those patients needing more complex dental surgery will be referred to the Swedish Community Specialty Clinic housed within the hospital. The clinic offers procedures that the local health centers may not be able to handle, such as difficult extractions, surgeries for pre-prosthetic preparation and medically complex patients. The clinic accepts Medicaid coverage. It will provide the service at reduced cost for Medicaid patients and free for uninsured patients under a certain income threshold who cannot afford to pay.

At the specialty clinic, an attending dentist treats patients and oversees residents working with patients. A volunteer oral surgeon comes in every week.

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"The need is great. We get about 300 referrals a month in the county," said Jennifer Freimund, executive director of the Seattle-King County Dental Society.

With this program, patients have quicker -- and more affordable -- access to dental surgeries. Before, Vander Beek said, choices for patients were severely limited because these services are so expensive and few dental surgeons accept Medicaid.

"There are various places we would try, but there wasn't a consistent or reliable source for our patients," she said. "An oral surgeon may take a limited number of Medicaid [patients] … maybe only on Mondays and they're booked out for eight months."

Demand for services has increased in Washington since it reinstated Medicaid dental benefits for adults in 2014, when it was expanding the Medicaid program under the federal health law. That brought an influx of patients who needed advanced dental care.

Medicaid dental coverage for children is required by federal rules, but it is an optional benefit for adults and is often the first to go when the state has budget problems. Even when Medicaid patients do have dental coverage, it can be difficult to find a dentist who would accept them because of low reimbursement rates. By the time the oral disease becomes severe, a visit to a health center may not be sufficient.

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"Connecting people with care not only addresses their issue of the moment, but it provides a foundation of understanding to them on where they can get a continual level of care," said Jane Grover, director of the council on access, prevention and interprofessional relations at the American Dental Association.

Among the type of cases health centers would refer to the specialty clinic are patients who have complicated medical histories or who might need access to a hospital setting and operating rooms.

Vander Beek said she referred someone recently who had rampant tooth decay. He was 37 years old and he had never been to a dentist. The health center could take all his teeth out and arrange for him to get dentures, but he would still be charged a fee on a sliding scale despite being uninsured. Vander Beek referred him to the center so he could get the treatment free-of-charge, which would then allow him to afford his dentures.

"I think it's a program that if replicated is a good model," Vander Beek said. "There needs to be more access for the most vulnerable folks, most of which are adults. There needs to be more robust services like this."

An Emergency Dental Diversion Initiative in Missouri also has a similar referral process between a local hospital and health center, while the University of Maryland School of Dentistry partnered with a hospital to open a dental clinic.

While programs like this that streamline the referral process are beneficial, another solution might be to hire dental surgeons in health centers to deal with the complex procedures. But center officials say they are already struggling to keep even dentists on staff, with pediatricians taking over the responsibilities in some cases.

"The most significant reason that federally qualified health centers do not have oral surgeons on staff is because they're lean fighting machines because of budgeting and funding," Freimund said. "A specialist costs more than a generalist."

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