Need Assessment Committee Meeting Minutes February 22nd, 2019


Marcy Thompson & Amanda Lugg, Co-Chairs
February 22nd, 2019, 2:00PM -4:00PM

Cicatelli, 505 Eighth Avenue, 20th Floor LAVENDER ROOM New York, NY By Conference Call – 1-866-213-1863, Access Code 3587454#

Members Present: Paul Carr, Billy Fields, Carol Kunzel, Charmaine Graham, Dorella Walters, Jan Carl Park, John Schoepp, Leo Ruiz, Rob Walker

NYC DOHMH/PHS Staff Present: Nadine Alexander, Leslie Brandon, Julie Lehane, Kimbirly Mack, Darryl Wong, Scott Spiegler

Welcome/Introductions/Moment of Silence/Public Comment/

Co-Chair Paul Carr opened the meeting with introductions. John Shoepp led the committee in a moment of silence.

Review of the Meeting Packet/Review of the Minutes:

Melanie Lawrence took us through the meeting packet and agenda. No minutes

Conference Call with Dr. Judy Moy

Mr. Park explained the findings from the conference call with Dr. Moy: Dr. Moy has been treating patients with HIV for over 12 years. She strongly advocated for more funding for prevention. She recommended more cleanings. PLWH often suffer from dry mouth due to the meds. This can lead to bone degeneration and a number of other conditions which lead to a need for more extensive oral health care.

She does her best to find funding for the services her patients need – this often means cobbling funds together. Some of her reimbursement rates are astonishingly low, especially when compared with private practice. 

Implants are practically impossible to get covered. Recently Medicaid has indicated they will pay for implants – but only to hold a denture in place. Not everyone is an eligible candidate for implants. 

People who are in and out of care – such as care coordination clients – pose an extra challenge – because it is difficult to get them the consistent care they need.

Dr. Moy talked extensively about stigma, and how difficult it is working with patients who have experienced such treatment. Patients also have the normal issues that arise around seeing dentists. 

Maybe we just create a table on covered services and then see where the gaps are. 

Ms. Lehane discussed the similarity of issues that come up for the RWPA dentist in Tri County. Medicaid will pay for some things – two cleanings a year. One scaling every 3 years. The dentist in Tri County does a whole rule out to get to POLR – timing is very important. 

HMOs require pre-authorization – when they deny services, RWPA can pay for it. Some services, like orthodontist work, crowns, etc – hard to find payers – this is what RWPA ends up paying for. Things like gum grafting. Folks with lower immune system issues can have gum issues. Some of these things are not paid for. Many things get paid for – but not in a way that is timely enough. And then there are other services that are very expensive, and do not get paid for – even if they are necessary. 

There is a great deal of paperwork – which is required to avoid fraud – but it creates a heavy burden on the provider. The reimbursements for services are very low – which leads to a small network of folks willing to do the work. 

Ms. Brandon discussed bringing social work and dentistry together. Even for an average person – dentistry can be incredibly frustrating. Unfriendly dentists, scared patients, short time for the procedure – complicate everything further. Patients do well when they are prepared – they know what’s going to happen and what to expect – they are able to comply. 

Ms. Brandon explained how she would work with patients – before and after the procedure. At Columbia School of Dentistry she worked with patients to pay down on the materials and services to make them accessible. The most important thing is the dental diagnosis and the full set of x-rays. Over your lifetime it is cheaper to keep your teeth. Dentures don’t work for everyone – if they rock in your mouth you cannot eat.

Dr. Moy told us about social isolation on top of oral health issues and the normal issues of phobia around dental care. Didn’t think about this with Food and Nutrition even though we included textured foods so it would be accessible. Need to think about the social work aspect. Dr. Moy is offering counseling in the dental chair – this puts even more burden on her. We can be doing this work in a better way that is aligned with whole health.

Social workers at the dental school in Columbia are incredibly busy. Issues of personal characteristics of provider and patient – issues about access, quality of mediation, patient adherence. Big issues is patients do not return. Complex lives – maybe services are not suitable. But where can we focus.

Ryan White (RW) will pay for support services. And that’s a benefit. How aware are providers that they can tap into RW funds – they must be RW funded. Medicaid has a network, but if it’s not covered by Medicaid, then you’re out of luck. 

Strange that we are talking about people’s sex lives but we don’t ask about their oral health.  Very little conversation about the data system RW uses. There is very little consciousness about what needs to be asked. 

Columbia originally hired a social worker to connect the concept of the head and the mouth in the mind of patients. People aren’t thinking about these things – not thinking about people being able to chew. 

At God’s Love We Deliver – they screen for oral health and offer a complement of textured diets. Those questions do not come up in eShare. Changes to eShare are difficult but agencies and programs can be directed to do supporting assessments to ensure the needed referrals and linkages happen. This could be a project for the quality management team.

A few years ago during the meningitis outbreak, you were constantly asked if you had been vaccinated. If the DOHMH got behind these oral health issues, it would happen. Some doctors ask regularly about dental – others don’t, so this is a practice that should happen there as well. 

EShare can be changed – draft questions that should be included and submit it to the recipient. If we want oral exams as part of the regular check up – this has to be the guidance issued. 

RW doesn’t pay for medical care – makes it difficult to influence how it works (but can possibly do this through COTA).

It’s clear that RW patients need to be covered for at least 4 cleanings a year. Should be thinking about how people can take advantage of this system. Should be a way to smooth the process. Must put in for a service and wait for a denial letter – but the dentist is not saying that the wait is the issue. 

EMA services apply to the entire EMA – so folks in Brooklyn can access services in Tri County. 

Oral Health was cut due to the availability of other funded services. But the portfolio sustained a very large cut – which necessitated the chopping of the service category. When this work started – working with PLWH – people were dying. They got AIDS diagnosis and a 12 month prognosis. Now the landscape has changed and people are aging and we need to be thinking about how the portfolio changes.

The Planning Council is  not permitted to fundraise. 

Looking at what is being offered in Tri-County as an outline for what we do in NYC. 

The medical case management team should be asking people about their oral health. There should be at least a question about oral health in eShare. But oral health should be integrated beyond medicals and on medical case management. 

Read Tri-County Oral Health Service Directive as a committee.

We should add a citation to HIV Dent. We should go further and advocate for the standards from dentists that care for PLWH. As long as the enhanced standard does not contradict the ADA standards. 

We should make a reference that directs folks to be referred to ADAP. In Tri-County everyone has a case manager – this is not true in NYC. If you show up at any RW service you should get benefits enrollment – but that is not the emphasis for all the services in the portfolio. In NYC we would want to ensure that patients were getting access to all benefits. 

Are dental prescriptions covered? Can we help with that? What does ADAP cover? Dr. Moy has never seen this information in writing. ADAP fully covers dental prescriptions. 

We need a better understanding of bone grafts and implants to be clear on what, when and how they should be covered. 

Are there dental services available in the 5 boroughs – is geographical access a bigger priority than colocation?

Callen Lorde does nights and weekends. A re-assessment is just re-certification. 

Homework: Think about questions to bring to include into eShare.

A directive is an outline – details are fine, but can box providers in in ways that do not serve the population. 

Mr. Park walked us through his dental diagnosis – and how expensive it is to get care.

Any tooth that is missing creates instability in the mouth. Can’t we get root canals and crowns covered? Temp caps are not that expensive. People are stigmatized when they don’t have teeth and a nice smile. Also need to think about the type of materials that are being used – Dr. Moy won’t use the bottom of the line because those won’t serve the clients. 

New Business