Integration of Care Committee Meeting Minutes May 20, 2020

Members Present: Danielle Beiling (co-chair), Donald Powell (co-chair), Annette Roque,  Randall Bruce, Paul Carr, Mitchell Caponi, Bettina Carroll (non-voting), Dorothy Farley, Billy Fields, Ronnie Fortunato, Janet Goldberg, Deborah Greene, Bill Gross, Christopher Joseph, David Klotz, Peter Laqeur, Leo Ruiz, John Schoepp, Claire Simon, Brenda Starks-Ross, Joel Zive, Graham Harriman, Rose Chestnut, Mary Correa, Stephanie Serafino

Members Absent: Lauren Benyola, Michael Ealy, 

DOHMH Staff: Kimbirly Mack, Guadalupe Dominguez Plummer, Ashley Azor, Eleonora Jimenez-Levi

Welcome/Introductions w Pronouns/Moment of Silence/Review of the Meeting Packet/Review of the Minutes:

Ms. Lawrence & Ms. Beiling opened the meeting with introductions with pronouns and an icebreaker. Mr. Carr led the moment of silence. The minutes were accepted. 

Mr. Joseph offered to share his chicken tortilla soup recipe with the committee

Public Comment/New Business            

None.

A Conversation with Tri-County Oral Health Care Providers

(Please note that numbered, bold questions were on the agenda. Questions in italics were generated during the meeting. All answers are paraphrased and not direct quotes from providers/committee members)

Dr. Praff and Connor O’Shea introduced themselves as the providers of the Ryan White Oral Health Care services in Tri County. Have a mental health and oral health program on site, operating for over 30 years. Goal is to exam, diagnose, treat, educate and maintain oral health among clients.

1. What are the barriers that keep PLWH from accessing oral health care?
   1. What would help more people access and be retained in care?
   1. Have you seen any efforts that were successful in improving utilization?

Focus only on HIV population – try to get patients in every 3 months. Behave like a private practice. Work with case managers and other support services, especially transportation – that’s a big issue up here

• What are common issues you see in this population? 
  • Is there adequate coverage for the scope of work needed?

Most patients have neglected their oral health. Major problem is lack of awareness and neglect.

• Is there a significant need for more complex treatment?
  • How are more complex treatment plans achieved?
  • How much is reimbursed, if any, for implants? 

In theory, our patients should be covered, but we have to activate the grant a lot. A lot of issues with procedures that aren’t covered – or timing issues – length of time between dentures, or fillings, whena patient needs the service at that time. Cleanings are only allowed every 6 months – but need more frequent treatment, like every 3 months. And with Medicaid, if the patient has not met the spend down, must activate the grant.

Do general dentistry, but nothing with implants – although we would like to. You see a lot of demand, but can only refer them out. Implants are the future. 

Is need for implants cosmetic or functional?

Not aesthetic, it is functional. Helps with many things. Very important when you have a treatment plan – when you pull tooth, an implant solves the problem long term – other solutions cannot do this.

Implant compared to alternate solutions?

May work out the same.

• Where are the gaps in coverage? 
  • If you had a wishlist for what was covered – what would it include?
  • What services are needed beyond what Medicaid is able to pay? 
  • Given the Ryan White Program’s payor of last resort requirement (meaning – we can only pay when no one else covers the service), how could Ryan White Part A funds help support the overall health outcomes for patients if used for oral health care?

Do a lot of dentures – patients need a lot of teeth pulled – get the denture made and insert it the dayt he teeth are pulled – but no one covers those dentures. Not medicaid, not ADAP. This is a big part of practice bc don’t have implants, so do need a denture..

Cannot cover bone grafts under the grant.

See issues with bone disease – try to really educate them and see them every 3 months. Referrals to oral surgeon are smooth.

How burdensome is the RW payer of last resort?

Use RW when we need to fund deep cleaning, crowns, bridges when on that day the patient isn’t covered – that happens a lot – but then we make sure they get insurance.

Everything we do can be covered by the grant or a funder like Medicaid.

Can you talk about role of health education?

Very important to educate the patient – it really works and makes a big difference – every dentist should do it – we cannot bill for it – but it is integral to our work. We send reminders 2 days before and that day. If there are issues work with case manager and transportation company. We don’t penalize patients for missed appointments – we educate them.

Reimbursement rates? Are these sufficient to cover the costs?

Don’t have that info in front of us right now.

• Coverage:
  • How many of your clients access other dental coverage than Medicaid?
  • How are undocumented persons getting oral health care? How is it funded?   
  • On average how much does it cost to serve the needs of one person’s oral health care needs in a year? 

Clients have Medicaid and ADAP for the most part. Undocumented patients sometimes have ADAP and receive the same treatment as everyone else. Maybe 5-6% of patients are undocumented – have not seen a drop off in that number since 2016.

How do you handle emergency care?

Same day – if clinic is open. When clinic is open, patients can walk in anytime.

Demand for implants?

Recently have seen a high demand – when a patient loses their teeth – we do the bridgework but there is no current path to implants. Have rarely seen issues with implants – they have the lowest post maintenance requirements. 

• When, if ever, do you have waiting lists?

No waitlist. If a person calls for an appointment can get one that week. 

 You would include implants and bone grafts – but would this result in a lack of regular services for patients? If you had the same amount of money would you use some to fund implants and bone grafts?

This would depend on volume and need – anytime you move money to a different service, you would see less of another service. Would need a better understanding of the demand. But we can do these things. 

Who are the funders?

Medicaid is about 65% of patients.

Discussion of Draft Oral Health Directive

Can be difficult to access oral health care services in NYC due to location.

Draft directive was pulled from multiple sources. Requires line-by-line editing. Consists of multiple components: 1. Dental navigation to increase system capacity and 2. develop guidance to accessing complex treatment. Navigator does not work directly with consumers necessarily, though can be deployed for reminders. 3. Basic services, including 4 cleanings per year, dentures, etc. 

Committee began reading through the document.

Mr. Carr asked if we can address bone loss in the document.

Comprehensive treatment services should be removed. Removed word expensive. Melanie will edit in track changes (*this did not happen).

Public Comment

None.