Special Needs Dentistry
Elwyn operates two quality dental practices in the Philadelphia area serving over 3,000 patients with special needs. Its newest practice is located in West Philadelphia at 4040 Market Street. These practices serve people who have historically been underserved, such as individuals with intellectual and other disabilities. A number of key features including experienced staff, state of the art equipment, electronic dental records and a variety of funding sources have resulted in the success of these clinics. Participation of dental students from the University of Pennsylvania and Temple University enable the clinic to function within the Medicaid reimbursement rate structure. Serving people with special needs, such as intellectual disability or autism spectrum disorders, requires a unique skill set and results in the hygienist and dentist spending more time with each patient. Students are also introduced to new skills and experiences that will better enable them to care for the unique needs of this population when they open their own practices.
With the closing of state developmental centers in Pennsylvania and across the United States, increasing numbers of people with intellectual disability have been receiving community-based health services. This is a trend that has been occurring in the United States for the past several decades. Much of this change in service delivery has been funded through the Home and Community Based Service Waiver. This waiver allows the states to draw down federal matching funds for a list of services that have been agreed upon by the state and federal government. As a result, there are now far more individuals living in the community than are living in state developmental centers.
In Elwyn’s experience, community access to dental care for people with disabilities has posed several unique challenges. Finding a dentist who is skilled in treating those with behavioral challenges, clinic accessibility and a lack of available appointments create potential barriers to care. In addition, many patients with special needs also have communication difficulties and are unable to express pain in more traditionally expected ways. This may result in a failure to detect significant dental issues and lead to serious behavioral issues such as self injury and aggression. Many individuals also have difficulty cooperating with routine dental maintenance needs and are at increased risk for dental and periodontal complications caused by the long-term use of certain medications. Inherent maxillofacial abnormalities that occur in certain disabilities, such as Down syndrome, may also increase the probability of a dental problem.
History of the Problem
The surgeon general’s 2000 report “Oral Health in America” concluded that people with mental retardation or other developmental disabilities have significantly higher rates of poor oral hygiene and a greater need for periodontal disease treatment than the general population. The surgeon general also determined that good oral health for all Americans can be achieved through community, provider and personal services and programs. However, the report also notes that almost two-thirds of community-based residential facilities report that inadequate access to dental care is a significant issue. It also highlighted that a lack of available and accessible dental providers trained to serve people with special needs and limited third-party support complicate what is already a difficult segment of the society to support. In 2002, Elwyn participated in a second surgeon general’s conference, Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation. Similar conclusions were reached for people with disabilities. Primary and specialty sources of care were found to be poorly distributed, inadequate in number and ill-equipped to respond to their needs.
People with special needs are often covered by public health insurance, such as Medicaid. This can make finding a dentist who is both able and willing to treat them and who accepts their insurance extremely challenging. Similarly, Cohen and Manski (2006) reported that people with low incomes are more likely to obtain dental care outside of private dental practices. The situation has been further exacerbated by tightening Medicaid eligibility for services. This study found that poorer people tend to use physicians’ offices or emergency rooms when they need dental care and are 32.5% more likely not to seek formal dental care, as compared with a 19.7% rate for middle- or high-income individuals.
Elwyn’s Dental Model
While the above circumstances present a significant challenge in designing and providing dental services for people with special needs in Philadelphia, Elwyn’s dental clinics have taken steps to successfully provide oral health care. Elwyn’s business model includes serving a wide variety of people with special needs, including people with disabilities of all ages, people with autism spectrum disorders, those with mental illness, the frail elderly and disabled veterans. In addition to this mix of patients, Elwyn also accepts a wide range of insurances, including Medicaid, managed care Medicaid plans and private insurances.
The Elwyn model is very efficient. Patients are scheduled according to their individualized needs so that appointments operate smoothly and with few complications. Through the use of dental students, a calm familiar environment and highly specialized desensitization strategies, Elwyn is able to schedule almost the same number of patients seen in a more traditional office setting. This results in increased revenue and lowers fixed overhead expenses. A state-of-the-art dental software system also enables Elwyn to schedule and track appointments effectively, invoice insurance companies electronically and track and apply receivables in an accurate way. Patient insurances are billed for all covered services and ensure maximum reimbursement.
Most patients seen at Elwyn for the first time have not had a comprehensive evaluation by a dentist for quite some time. Their oral health has deteriorated significantly and requires extensive services to restore optimal dental health. Costs are initially quite high. However, as oral health is restored, patients move to a preventative maintenance mode. Maintaining a regular schedule of dental evaluations and cleanings helps to avert the vast majority of dental emergencies and results in lower overall costs to the system.
Elwyn also conducts extensive outreach into the community to make people aware of services that are available. Outreach initiatives have included presentations to managed care organizations, facility-based providers and local advocacy groups. Oral screenings at local health fairs have helped to identify potential oral health problems and have enabled Elwyn to connect patients to the proper dental services.
Elwyn’s Dental Services
Elwyn currently operates two full-service, general dentistry practices. The original office, located on Elwyn’s Media campus, was opened in response to the overwhelming need for dental services for those with disabilities. Elwyn later expanded dental services to include a second site in West Philadelphia. Through a generous grant from the Philadelphia Health Care Trust, Elwyn was able to build an entirely new and modern office. The Philadelphia practice now serves over 1,000 patients who range in age from 3 to 90 years.
Services provided include dental examinations, cleanings, x-rays and panographs, restorations, periodontal therapy (including scaling and root planning), endodontics, prosthodontics, extractions, crowns and behavioral supports. The Media site also offers conscious sedation one day each week for those who require this service. The need for sedation decreases over time as the patient becomes more familiar with the dental team and oral health begins to improve.
Many people with special needs require extensive dental care when they first arrive for treatment. Elwyn’s dental team provides the extra time and attention needed to help these patients acclimate to the dental office environment. Staff have been specially trained to care for those who are anxious, fearful and resistant to care. Through increased exposure and positive experiences with the Elwyn team, most individuals readily participate in preventive care visits and have greatly improved their oral hygiene, thus reducing the need for more expensive and intrusive procedures. There are very few private practice dentists in the Philadelphia area who treat patients with disabilities. This makes Elwyn’s dental practices the sole source of quality dental care for those with disabilities. Long waiting lists for services have been eliminated and people with special needs now have a “dental home” in which they receive regular, ongoing dental care. In partnership with the University of Pennsylvania and Temple University Schools of Dentistry, Elwyn offers unique, hands-on experience for the dental students and remains highly committed to the continued training and mentoring of the next generation of dentists. As these new providers become increasingly receptive to providing dental services to people with special needs, Elwyn anticipates further expansion of the dental home.
Cohen, L. A. and Manski, R. J. 2006. “Visits to non-dentist health care providers for dental problems.” Family Medicine 38: 556–564.
U.S. Department of Health and Human Services. 2000. Oral Health in America: A Report of the Surgeon General. Washington, DC: Office of the Surgeon General.
U.S. Department of Health and Human Services. 2002. Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation, A Report of the Surgeon General. Washington, DC: Office of the Surgeon General.
Elliott W. Simon, Ph.D. is currently the executive director of research and health services for Elwyn, a large human services agency that annually provides supports for over 13,000 people with special needs. Dr. Simon is responsible for audiology, behavioral, dental, genetic, medical, nursing, and physical rehabilitation services at Elwyn. A licensed psychologist who has worked for close to 30 years as a clinician, researcher and administrator in the field of intellectual disability, Dr. Simon is a graduate of Emory University with a doctorate in psychology. Clinically, Dr. Simon specializes in individuals with intellectual disability and co-occurring behavioral health disorders. His research interests include developmental disabilities and psychiatric disorders, particularly behavioral and cognitive profiles of genetic syndromes, diagnostic issues and the history of intellectual disability.
Karen Helker, MSN, RN is currently the deputy director of research and health services at Elwyn. Ms. Helker oversees all aspects of clinical operations for dental, medical and nursing services. She is a graduate of Villanova University and holds a masters degree in nursing administration. Ms. Helker has held a variety of leadership positions in large psychiatric and acute care hospitals. She also functioned as the director of case management for one of the nation’s leading providers of managed behavioral health care.