Health Resources and Services Administration (HRSA) funded health centers provide health care services for more than 27 million people. In 2017, 78% of health centers had a dental program, serving over 6 million people. Of all health center patients, only 22.5% of them received dental services at health centers. The National Network for Oral Health Access (NNOHA) is a HRSA National Cooperative Agreement awardee funded to support health centers in expanding oral health services.

In support of the Oral Health Infrastructure (FY19) funding opportunity, NNOHA has developed this toolkit as a guide for health centers to use in their efforts towards infrastructure enhancements that provide new or enhance existing integrated oral health services. Feedback from the 2018 HRSA Oral Health Service Expansion (OHSE) regional listening sessions was also used to inform the development of this toolkit. This toolkit will assist health centers in assessing their readiness for oral health service expansion, provide links to HRSA’s requirements, regulations, and resources, and offer infrastructure enhancement and expansion strategies for community health centers that have either on-site dental services or no current dental services.

When planning for the initiation of expansion of oral health services, health centers should review the following resources:

• Health Center Compliance Manual to understand and ensure compliance with the Health Center Program requirements

• BPHC’s Oral Health and Primary Care Integration website for resources on improving oral health and primary care service integration in health centers

• Sign up for the HRSA Primary Health Care Digest, a weekly newsletter containing information and updates pertaining to the Health Center Program, including upcoming oral health training and technical resources and competitive funding opportunities

Start by assessing the following factors to determine if starting a dental program or expanding an existing dental program is feasible to meet an organizational need and/or increase access to dental services for the health center service population.

• Level of need for dental services in the health center service area population: HRSA health center grantees are required to provide preventive dental services either directly, through a formal written contract/agreement, or through an established arrangement.Health centers may also elect to provide additional dental services beyond the required preventive dental services. Signs of a need for dental services include inappropriate emergency room utilization for non-traumatic dental needs by health center patients, demand for dental services by the health center primary care population and/or community demand.

Health centers already operating on-site dental services, may have insufficient capacity to meet the dental needs of the service area population. Signs of insufficient program capacity include:

• Long wait times for dental appointments

• Inability to complete recommended treatment plans

• High rates of drop-in emergency visits with multiple return visits for the same condition

• Low rates of appointment compliance

• Decreased satisfaction by health center patients and staff with the dental program

• Level of access to community dental providers for the health center population: If the health center is located in a community with an adequate network of dental providers that accept Medicaid beneficiaries and offer payment options to low-income patients so that the health center service area population has adequate access to dental services, then the health center should evaluate the network of dental providers in proximity to the service area to determine the best site(s) for expansion.

• Level of organizational confidence to provide dental services sustainably: The cost of providing dental care compared to primary care can lead to long-term fiscal challenges if not managed. Health centers considering starting a dental program, should have a business plan with estimates of both the capital costs of a dental clinic build-out and the expenses and anticipated payer mix and revenues for the dental program. Health centers with data that shows they will be able to operate and fiscally manage an on-site dental program sustainably should consider proceeding with implementing a dental program. Health centers with existing dental programs that are not, at minimum, revenue neutral, should proceed with caution if considering additional expansions.

While the most common method of starting or expanding existing dental  services is to build-out a brick and mortar dental clinic, there are  other options, especially for health centers that already have existing  dental clinics. The access point strategies are diagrammed and described  below: