Service Delivery Model
Upgrading access and delivery of dental
services to a special needs group
Identifying the Need
O
O
O
O
O
O
One dentist and dental nurse currently providing
dental care for a homeless population of 2,366
HSE funded initiative
Traditionally emergency service and
comprehensive treatment provided – Bottle Neck
Average of 750 appointments per year since 2003
Eligiblity for treatment depends on Medical Card
entitlement
Opportunity to upgrade service delivery to reach
more patients and remove the barriers to accessing
care
Barriers to accessing care
O Lack of available
O
O
O
O
O
information
Location and timing of
services
Fear and intimidation
from dental staff
Financial difficulties or
no medical card
The administrative
systems and the
attitudes of service
providers.
THESE NEED TO BE
ADDRESSED
Exceptional/High Risk
O Clause activated - November 2011
O Medical Card holders eligible for full range of
dental treatment by virtue of their dental
vulnerablility (see Appendix 1)
O PRSI scheme (social insurance) abolished
2009 and Medical Card limited to 2
emergency fillings per year in 2010
O Private GDPs are willing to accept referrals
from Homeless services where they weren’t
previously
Determining Priorities
O The priority is to increase access
O
O
O
O
O
for homeless people to dental
services
Provide them with information on
services available
Establish rapport with patients to
alleviate fear
Provide assistance with medical
card application
Determine their dental need and
provide relief of pain as priority
initially.
Provide support for General
dentists who are willing to accept
the patient referrals, by means of
telephone and visits where
necessary.
Identifying Objectives
(SMART)
O S- Assess 30 per week for level of need, medical
card status/eligibility and Triage and refer to
suitable GDP/MQ emergency
O M- Record number of patients attending
screening sessions and number of patients
attending for Emergency relief of pain. Follow up
with dental practices with phone call to measure
level of attendance for consultation and follow up
treatment.
Identifying Objectives
(SMART)
O A- Success of screening, triage, referrals
satisfaction of patients and GDPs
O R- Target Number of patients per week is 30
Target number of GDPs in the referral pathway 8.
Is this sustainable? Necessary? Other factors
preventing us reaching target
O T- Time frame of 6 months for a pilot with a 3
month reflection period
Programme Implementation
O Identified 8 units to be targeted for screening chosen
due to existing referral pathway with dental services
and previous presence in these units
O Units differed in type of homeless service day
center/residential setting/methadone treatment
center
O Age profile and level of level of dependency differed in
units
Meet Staff in Units
Unit
date
Response
O Orchid House
19/01/12 Positive
O Sundial House
19/01/12 Positive
O Focus George’s Hill 20/01/12
Positive
O Focus Coffee Shop
24/01/12
Positive
O Castle St.
26/01/12
Positive
O Trinity Court Pearse 24/01/12
Positive
O Merchant’s Quay 31/01/12 Negative
O City Clinic Amiens 07/02/12
Positive
Meeting Summary
O Outline proposal to use premises
O
O
O
O
for dental screenings for clients of
the facility
Explain that clients should be
assisted by units to apply for
medical cards via the ‘Fast Track’
Online service
Clients will be listened to and
examined to ascertain their need
and matched with a suitable
dentist
Emergency dental care available
in MQ 2 days per week without
medical card
Any Questions from staff
answered
General Dental Practitioners
O Contacted GDPs in the Dublin
city center areas by phone for
willingness to accept referrals
from Homeless services
O All clients eligible for treatment
under Medical Card
Exceptional/High Risk clause
O Eight accepted proposal
O Create positive relationship with
reception staff/dental nurse and
the senior dental nurse for
Homeless services to ensure
efficient referral pathway
Clinical Dental Technician
O A Clinical Dental Technician or CDT is a registered
Dental Care Professional who is trained and
qualified to provide a range of denture services
directly to patients.
O Eight in Rep. Of Irl one of whom is close by in
Dublin
O Referrals made for all dentures in same manner
as to GDPs with Medical Card subject to approval
Dental Screenings
O January 2012 to June 2012 – 18 screenings carried out
O Assess Med card status & provide support for medical card
O
O
O
O
O
application
Examine using Denlight
Discuss patient needs and wants
Discuss suitable venue for treatment
Explain Exceptional/High Risk clause subject to approval
Get Patient details to contact later that day
Triage
Form
Eligibility
Form for
GDP
records
Administration
O Back at base check Med Card status & PPSN
O
O
O
O
O
(personal public service number)
Make best match with GDP & client
Make referral calls if not already done during
screening
call client with details of referral
copy screening form & eligibility form and post to
GDP
Follow up phone call 1 week later to GDP and
client
Mid Point Reflection
O At 3 month point in project
O GDPs – 10 more requested to join the referral
O
O
O
O
pathway
Units – positive response asking for sister satellite
units to be screened in the future
Clients – suitable clients were referred by staff of
units to GDPs with advice from Homeless unit
Information – Medical card eligibility, access to
dental services more readily available to clients in
their own units
Emergency treatment in MQ still heavily subscribed
Table 1: 6 month evaluation Number
of clients screened and referred
Number Screened in Units
216
Number Referred To GDPs
180
Number Referred to CDT
12
Number Treated for
36
Emergency Care MQ following
screening
Number taken on for
comprehensive care by
Homeless Service
8
Number Attending MQ as per
usual for Emergency Tx
69
Total number of sessions
(am/pm)
48
Making sense of the figures
Table 1
O Number of clinical sessions Jan-June 2012
Screening + MQ emergency = 48
O Total number of clients seen- 216 Screenings
+ 69 Emergency MQ = 285
O Av. Number of clients per session = 6
O Session is AM or PM
Table 2:Number of procedures carried out
2008*,2007,2006,2005
* week 9 2008 to week9 2009
Appointments
Emergencies
Fillings
Extractions
Dentures
Root
Canal
946
301
769
207
198
739
329
479
214
40
4
917
332
577
324
45
45
755
309
465
427
81
15
10
Making sense of the figures
Table 2
O Total number appointments annually- 839
O
O
O
O
Av.
52 weeks in year minus 9 weeks Annual
Leave/Bank hols/Sick leave etc = 43 weeks
7 sessions per week x 43 = 301 sessions
Av. number of clients seen per session - 2.8
Many of these clients were repeat visits. In
2008 there were 279 individuals treated
over 946 appointments. Compare this with
289 in 6 months pilot 2012
Figure 1: Number of Clients catered to
per session in 2012 compared with
previous years
6
No. Clients
5
4
3
2
1
0
2005
2006
2007
2008
2012
Figure 2:Referral outcomes with
GDPs & CDT & Homeless Dental
57
60
50
47
36
40
30
20
12 14
10
0
GDP
Tx Complete
8
2 2 0
CDT
6
9
2
2
North Strand
Tx Incomplete
DNA
8
12
3
MQ
Emergency
Don't Know
Supported Medical Card
Application
Successful
Application
No Application
Discussion
O The initial findings suggest more clients are
O
O
O
O
being cared for
Administration - Labour intensive
Evident by the fact that there is a high number
of clients in the ‘Don’t know’ category of the
follow up data
Of the clients referred to GDPs 44% are non
contactable for follow up
It is unrealistic to think that the service could
move forward without the support of dedicated
staff, at least a specialist dental nurse and
ideally a specialist dental team
Discussion
O Attendance at the Emergency
drop-in in MQ is still heavily
subscribed lending support to the
belief that the chaotic nature of
homelessness does not marry well
with an appointment service
O What the client ‘wants’ and what
they are capable of is often at
odds
O The most successful referral
pathway is to a GDP who operates
a ‘walk in’ service in Dublin 1
O Sometimes the city needs a whole
warehouse dedicated only to
Bananas
References
O Slide 1http://www.homelessagency.ie/Facts/Homeless-
Figures.aspx ‘Measuring Homelessness’ accessed
12/01/12
O Slide 3
Holohan T (1997), “Health Status, Health Service
Utilisation and Barriers to Health Service
Utilisation
among the Adult Homeless Population of Dublin”, Dublin,
Eastern Health Board
O Slide 14
http://www.cdtai.ie/ Clinical Dental Technician
Slide 23
HSE Special Needs Dental Report 2007, 2008