Introduction

The Department of Community Dentistry, University of Texas Health Science Center at San Antonio, Dental School organized and coordinated the project Texas Initiative for Dental Public / Community Oral Health Infrastructure Development. This effort was funded by the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), USDHHS.

The project goals were to:
a) Develop a strategic plan to help ensure a viable community oral health infrastructure in the state of Texas,
b) Plan community oral health professional education, training, and leadership opportunities, and
c) Enhance dental public/community health accessibility to underserved populations in Texas.

The Workshop participants developed a broad-based collaborative plan to improve oral health for children and adults in Texas. Workshop participants included representatives from diverse organizations, agencies, professional and advocacy groups with a keen interest in improving access to oral health services and reducing oral health disparities in Texas. The Workshop involved individuals from the public, private, and non-profit sectors. A Planning Work Group met twice prior to the workshop to plan activities for the workshop.

The workshop was developed with the intent to enhance ongoing local, state and national activities such as:
National Governors Association (NGA) Oral Health Policy Academy Initiative
Healthy People 2010 Oral Health Objectives
Surgeon General's Report, Oral Health in America
Texas Department of Heath Strategic Plan
Final Report, Review of the Texas Oral Health Program prepared by the Association of State and Territorial Dental Directors

In preparation for the Workshop the following background materials were distributed to the Workshop participants before the Workshop:
Surgeon General's Report, Oral Health in America: A Report of the Surgeon General, Executive Summary (2000)
Final Report, Review of the Texas Oral Health Program prepared by the Association of State and Territorial Dental Directors (September 1999)

The Workshop, "Shaping the Future of Oral Health: A Collaboration on the Infrastructure for Oral Health in Texas" was held at the Embassy Suites Hotel Airport, 10110 US Hwy. 281 North, San Antonio, Texas. The Workshop began with registration, orientation, and charge to participants on the evening of Wednesday, May 30, 2001 at 7:00 p.m. It continued through the next day, Thursday, May 31, 2001 and concluded at 12:30 p.m. on Friday, June 1, 2001.

Workshop Topics

Thirty eight persons representing various organizations throughout Texas attended the workshop.

It was the intent of this Workshop to provide leadership and direction for future endeavors with the goals of improving oral health and reducing oral health disparities in Texas.


Presentations were provided by invited speakers during the plenary sessions at the Workshop. The presentations included the following topics:
National and state perspectives: on oral health status and access;
Strategies to improve oral health through: legislative, policy, advocacy and community collaborative efforts; and
Building infrastructure and capacity to address oral health needs for children and adults at the state and local level.

Each workshop attendee was assigned to a work group based on several aspects of balanced representation and expertise. The work groups developed an action plan. The key topics of the work groups were:
Education of the Workforce,
Legislation and Policy Development, and
Community Based Actions through Collaboration and Advocacy.

Issues related to these topics were discussed within the work groups and prioritized (See Figure 1). Then the work groups proceeded to outline several strategies to resolve the identified priority issues

1. Under the topic of Education of the Workforce the following three issues were identified as top priority and the accompanying strategies reviewed:

Issues
A. Enhance and legitimize public health education at pre-license level for all health professionals, including need to teach about determinants of health, increased awareness of disparities in society, and public health leadership to create change; advocacy of leadership for change as part of academic culture.
B. Incorporate and implement cross-training and understanding with common theories and language which will facilitate better communication and cross-fertilization among health professionals leading to integration of oral health into health professionals education and curriculum (all disciplines).
C. Need to develop continuing education that will enhance dental and dental hygiene scope of practice and give stronger support to advanced level training in public health and its place in the career path.

Strategies
Identify core competencies with respect to oral health for various health professions
Provide leadership to change accreditation standards
Institutional curriculum mapping
Consolidate curriculum where overlap exists
Administrative “buy-in”
Eliminate administrative barriers such as modification of capitation formula
Cross disciplinary clinical training “train in teams who work in teams”
Develop and disseminate model
Ensure that oral health is included in overall health policy, education, and funding
Develop alliances with advocacy groups in support of issue
Conduct and disseminate research showing need
Identify and disseminate successful state models (e.g. Oregon)
Learn from nurse practitioner effort
Acquire support of Texas State Board of Dental Examiners (TSBDE)
Non-threatening marketing utilizing focus group(s)
Assessment of skills needed to address disparity

2. Under the topic of Legislation/Public Policy the top three issues were identified and the accompanying strategies reviewed:

Issues
A. Low Medicaid/CHIP reimbursement impact on number of participating providers.
B. Current scope of practice - need for expanded functions and mid-level providers.
C. Recruitment to dental professions should be tied to minimal loan repayment programs. There is a lack of career ladder.

Strategies
Build community awareness of the need for increased reimbursement

3. Under the topic of Community Based Actions the top three issues were identified and the accompanying strategies reviewed:

Issues
A. Lack of network among coalitions and public/private partners
B. Need for community development coalitions and/or collaborations
C. Lack of local public health infrastructure

Strategies
Development of public health infrastructure
Identify/activate leadership in local community (developing awareness of problem)

(See Figure 1 pages 6-8 for a complete list of issues from the workshop)
(See Workshop Blueprint on pages 16-27 for detailed information including short and long term actions related to the issues)

Evaluation of the workshop was generally favorable with participants emphasizing the need for future networking/planning opportunities like this workshop. As a follow up to the workshop the blueprint of issues, strategies and infrastructure development was mailed to participants to record the issues they would take action on in the future. Following is a list of activities either occurring at this time or planned for the near future:
• HRSA through the USPHS Regional Office is willing to co-sponsor a statewide Dental Summit to continue the planning and to begin implementation of parts of the strategic plan. HRSA is willing to contribute money and logistics support to co-host this summit.
• Texas Department of Health will sponsor a statewide Dental Summit
• An Oral Health Strategic Planning Workshop is being planned at the University of Texas, Houston Health Science Center. Issues relevant to oral health for children (0-16) will be addressed.
• Incorporate disparities in Oral Health in required minority health class for undergraduate Health Education Majors
• Teach Early Childhood Caries (ECC) screening to nursing students at UTHSCSA and integrate ECC screenings into well child exams done by nursing students in public health arenas
• Integrate oral health issues into research generated from the Center for Community Based Health Promotion for Women and Children at UTHSCSA
• Integrate ECC screening into research on determinants of child nutrition and growth
• Link dental hygienists to nurse practitioners who have been successful in broadening the scope of practice
• The El Paso Oral Health Commission will encourage dentists: to visit with physicians, attend medical society meetings, and to prepare articles for publication in the El Paso Medical Journal
• The El Paso Oral Health Commission will consider adding a physician as a member and a Public Health Institute member.
• Covenant Health Care System is willing to continue to interact with physicians at medical staff meetings and at peer review educational events to stress the importance of oral health in the total health care of the individual
• If congressional support continues HRSA will continue to support dental residencies through grants to dental schools from the Bureau of Health Professions. In the case of Dental Public Health, the support should include the MPH degree, and support for both the MPH Program and Residency should be extended to Dental Hygienists.
• Continue meeting with state and local officials, as well as serving on local legislative committees to expand the scope of dental hygiene practice, and to improve Medicaid reimbursement and increase providers. Work will also continue towards obtaining funding for the oral health needs of the elderly.
• Encourage participation of health care providers on coalitions addressing oral health issues
• Covenant Healthcare Systems is willing to assist other communities with input and expertise acquired from a community based health program for oral health that addresses care in rural communities and other areas
• As a member of the State Oral Health Advisory Committee Janet Bartlett will work with the committee to:
- implement use of regional dental vans for border dental care as legislated
- implement a pilot project to use school nurses for dental inspections and referrals of new students
- advocate for state assistance to communities needing collaboratives to meet oral health
- work for more Medicaid providers and to increase reimbursement fees
- support fluoridation in communities where there is none
• The State Oral Health Advisory Committee will:
- attempt to secure funding for adult indigent care in El Paso
- identify and implement alternative strategies for community oral health needs
- develop request for an adult oral health Medicaid waiver
- invite students from Texas dental schools to extern at El Paso's Public Health Clinics
- search for partnerships with El Paso businesses and hospitals for funding for dental vans for adult indigent care and for supplemental Medicaid reimbursement
- look to other states for successful program models for ideas to improve oral health care
The above activities indicate the success of this workshop as a collaborative effort of stakeholders throughout Texas to provide leadership and direction for future endeavors that will improve the oral health and reduce oral health disparities in Texas.

The Workshop Report has been developed and submitted to the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA) the agency supporting the Workshop and is available on the following website: http://dental.uthscsa.edu/texasaccess/

FIGURE 1:

CRITICAL PROBLEM AREA
Education
Prioritized Issues / Problems
Top three issues / problems in order of priority:
1. Enhance and legitimize public health education at pre-license level including need to teach about determinants of health, increased awareness of disparities in society, and public health leadership to create change; advocacy of leadership for change as part of academic culture.
2. Incorporate and implement cross-training and understanding with common theories and language which will facilitate better communication and cross-fertilization among health professionals leading to integration of oral health into health professionals education and curriculum (all disciplines).
3. Need to develop continuing education to enhance dental hygiene scope of practice including at certificate level training in public health.
Others receiving votes
Professionals in-training work more in community as part of education
Prepare lay health workers in prevention at certificate level
Access to all kinds of education at remote and rural sites
Scope of practice issues
Teach best practices related to community services
Access to continuing education (CE) for lay health workers and professionals

Legislation & Public Policy
Prioritized Issues / Problems
Top three issues / problems in order of priority:
1. Low Medicaid/CHIP reimbursement impact on number of participating providers.
2. Current scope of practice - need for expanded functions and mid-level providers.
3. Recruitment to dental professions tied to minimal loan repayment programs, lack of career ladder programs and opportunity for expanded roles.
Others receiving votes
Minimal coverage for non-citizens
Enrollment barriers related to Welfare Reform information
Lack of educational efforts on prevention to adults, elderly and employers
Lack of evidence-based practice guidelines
Dental workforce not keeping pace with population growth

Community-Based Actions
Prioritized Issues / Problems
Top three issues / problems in order of priority:
1. Lack of networking system among coalitions and public/private partners.
2. Need for more community development coalitions/collaborations.
3. Lack of local public health infrastructure.
Others receiving votes
Lack of support for empowering communities for mobilizing partnerships for supporting oral health initiatives
No centralized agencies to coordinate communication and community effort
Lack of network for coalitions/advocacy groups across local, state and national levels
Lack of local "expert" leaders/advocates to represent oral health issues within coalitions
Lack of incentives to be advocates
Lack of education/knowledge base of oral health care in existing coalitions
Lack of awareness of importance of oral health issues among other health care providers
Lack of effective communication between local political action organizations and state legislators
Lack of health education/advocacy coalitions