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Formation:
Because of long-term, restricted access, patients present with multiple health issues, to include serious dental health problems that put them at high risk for developing significant chronic illness, other complications or with already irreversible damage due to lack of diagnosis and appropriate dental care.

The rapidly increasing volume of uninsured patients, with needs for costly labs, diagnostic services, preventive and restorative dental services, and access to multiple medications,created tremendous challenges for our Health Center and placed additional financial pressures on the organization.

As a result, our partnership with the Alexandria Health Dept. was established to improve access to dental services. Through this dental collaboration the Health Department provides the physical space and dental operatory and ANHSI contributes eight hours of a dentist and a dental assistant to run a dental clinic eight hours per week. In addition, ANHSI provides all required dental and office supplies.

From the beginning, this dental program collaboration sought to meet an increasing demand for dental care from uninsured individuals and filled a major gap in access to dental services in Northern Virginia. It also served as an innovative approach for two organizations to leverage mutual resources and jointly meet an unmet, growing need.

As soon as our dental clinic opened at the Alexandria Health Department in the spring of 2004, we experienced a three-month waiting period for dental appointments. Uninsured patients were desperate for dental care; there were very few options for uninsured individuals to receive dental care in our area.

The need for services continued and in the summer of 2007, we expanded our partnership and added additional hours to our dental program with Arlington County Department of Human Services Public Health Division.

This partnerhsip/collaboration has enabled us to achieve remarkable success. Neither organization idependently could have acheived such meaningful success and impact. Since the collaboration's inception in 2004; 1) 217 dental visits have been held the following outcomes have,
2)3,555 uninsured patients have been served,3)All patients have been uninsured, 4)1,185 have been children and 5)2,370 have been adults.


Management:
Initial discussions regarding collaboration to expand primary dental care services took place between the Alexandria Health Department Director and ANHSI Executive Director and later on between Arlington County’s Public Health Division Chief and ANHSI’s Executive Director. Once overall collaboration issues were discussed and resolved, program management was delegated to a shared arrangement between ANHSI’s Executive Director and the corresponding Directors of clinical service at each Health Department. Both of these individuals defer any final decisions until the Dental Directors of each site have approved.

The management structure is purposefully simple and straightforward to allow for immediate solutions to any issues that may arise. Meetings are held quarterly in Arlington and as needed in Alexandria to review program outcomes and to plan for any future changes. The three essential staff involved in program management have open, accessible communication and equal commitment to the success of the collaboration assures smooth operation.

Challenges:
The major techniques to address the few challenges we have encountered are open communication and ANHSI’s willingness to respond quickly and favorably to requests from both Alexandria and Arlington.

We continue to arrive at solutions through a process of negotiation in which ANHSI is willing to concede to requests from both Arlington and Alexandria in light of their generous donation of space, equipment and staff support. When issues arise, a meeting is arranged and through open communication, solutions are developed and then implemented by the appropriate person.

Impact:
The primary goals at both dental sites is increased access to primary and preventive oral health care for low income uninsured adults and children in Alexandria, Arlington and surrounding communities. This collaboration has enabled ANHSI to provide care above and beyond what either Health Department is able to deliver. In the process of providing services, ANHSI has determined the need for additional services, especially for specialty care such as endodontics, crowns and prosthetics. ANHSI is currently negotiating with both Health Departments for additional chair time in exchange for ANHSI’s contributing funds to install new chairs and equipment.

ANHSI dentists work alongside both Arlington and Alexandria dentists, consulting with one another and sharing equipment and expertise as needed. In Alexandria, ANHSI’s dental assistant is the only staff member in the dental clinic who speaks Spanish, and she is called on frequently to translate for patients being seen by Health Department staff. Frequently patients seeking care at both Health Departments who are not eligible for care are referred to ANHSI dentists for care.

ANHSI’s dentist at the Arlington site did not have much experience working with patients needing prosthetics. He turned to the Arlington Public Health Division dentist for assistance and under his tutelage has been able to initiate denture services for ANHSI patients in Arlington.
The Arlington Public Health Division was in need of a Spanish speaking dental assistant and with ANHSI’s blessing recruited our part time dental assistant to a full-time position. ANHSI was able to replace the dental assistant; the dental assistant secured a full-time position with benefits as a result of recommendations from ANHSI and observations of her work by Arlington; and Arlington gained an experienced, capable bilingual dental assistant.


Model:
This is an excellent collaborative model between a private nonprofit organization and two public agencies whereby they come together to share significant physical, human, financial and management resources to achieve a common vision of serving a growing number of uninsured individuals in need of dental care.

The dental collaboration in Arlington County has served as the foundation for collaboration in other program areas leading to a current major initiative whereby we are jointly integrating primary care in a mental health site for seriously mentally ill patients. Collaboration is also under way to access medications for uninsured patients through the pharmaceutical companies’ Patient Assistance Program (PAP) by using a shared software program designed for this purpose.

The benefits of sharing space and leveraging resources have been mutually beneficial and has enabled all partners to enhance our programs and serve more people. This colloboration can easily be duplicated and expanded to other programs as evidenced in our new expansion of providing integrated primary and behavioral health care services.

Efficiencies achieved:
Describe the economic and operating efficiencies achieved by the collaboration.

a.Include the methodologies (including time frames) used to track changes.

Monthly, quarterly and yearly program and financial data is collected regarding the number of patients served, visits held, and operational aspects and costs. Logic Chart Methodology is used to identify (1) Contextual factors influencing the service; (2) Actions required in implementation; (3) Needed Outputs; and (4) Annual Desired Outcomes. An Evaluation Plan is also developed which includes key evaluation questions, methods used, who is responsible for collecting the data, and how often the data is collected and analyzed.

Program and financial assessment is conducted at least twice a year.

Both a Patient Satisfaction Survey and an Agency Partners’ Survey are conducted once a year.

b. Examples of financial savings, cost reductions, and/or increased revenues

Children pay $20 per visit; adults pay $40 per visit regardless of the amount of work that is done. All patients have been uninsured. No patient is denied services for inability to contribute a patient fee.

Patient fees in 2009 contributed 28% of all dental program costs.

Value of In-kind Donation Arlington County (Space, Operatory and Reception Staff: $21,800 per year

Value of In-kind Donation Alexandria City (Space, Operatory and Reception Staff): $15,792 per year

Total In-kind Donation to the Collaboration: $37,592 per year

Grant Contribution to the Collaboration: The dental program attracted a key donor, the Northern Virginia Health Foundation, which contributed financial support ($104,453) toward the establishment and operational costs of the Arlington dental program for three years.

c. Examples of increased program delivery.

The following patient and visits chart shows the growth in dental patients seen and visits held since the dental program opened in 2004 to June 30, 2010.

Year Dental Patients Dental Visits

2004 162 272
2005 305 440
2006 296 428
2007 472 771
2008 753 1,078
2009 1,052 1,497
2010* 515 731

TOTAL: 3,555 5,217

* Jan-June/2010

Quantitative Benefits to the Community

The primary benefit to the community is the increase in access to primary dental care from 272 dental visits in 2004 to 5,217 as of June 2010 (See 1c above) and a resulting improvement in oral health. The collaboration allows for the full use of all dental operatories throughout the week. Access is measured by monitoring utilization of services. (See also 1.b. above)

How are these benefits being measured and the significance of these benefits?

Prior to the collaboration, operatories would be idle for several hours during the week. A major public health challenge is to promote the health of populations. Oral health is critical to overall health status. It is especially important that children, pregnant women and adults with chronic illnesses enjoy good oral health.

In addition to the immediate effects of healthy teeth and gums, oral health has long term effects of preventing or detecting early infection that may cause preterm labor or the development of blood clots and systemic infection. For patients with diabetes, poor oral health sets off a vicious cycle of elevated blood sugar, worsening infection and further loss of blood sugar control.

Access to oral health care has long been overlooked by the health care community, and the lack of access has reached crisis proportions. This collaboration begins to address this major public and personal health issue by providing an efficient and effective model of low cost, quality primary dental care to uninsured, low income adults and children.








Evolution:

a. Decision to collaborate: Dental services for low-income, uninsured individuals are seriously limited in Northern Virginia. A study of approximately 415 adult ANHSI patients revealed that only 0.9% had a documented dental visit in the previous year. Patients, both adults and children, attending the Arlandria Health Center for primary care present with serious tooth decay, abscesses, crack teeth and gum disease. Many of these patients have never seen a dentist and have learned to live with discomfort and pain, self image and nutrition problems and threats to their overall health. Often patients present with a dental crisis – pain that does not allow them to sleep, swollen jaw and nowhere to turn. They have tried home remedies, but they no longer work.

In response to this ever present need and in the face of prohibitive private dental care costs, ANHSI decided to offer dental services; however, the initial investment, particularly for major equipment, was well beyond our budget. We approached the Alexandria Health Department about “borrowing” an operatory and “sharing” major equipment such as X-ray and autoclave, during times when it was not being used. Thus began our collaboration to increase access for low income patients.

Two years later we began similar conversations with the Arlington County Department of Human Services, Public Health Division, when we discovered that they had an operatory that was underutilized, and we now have a dental program there two days a week. If it were not for this in kind support from both health departments, ANHSI would not be able to provide basic dental care to a population that otherwise would go without.

Our patients (11,353 seen in CY 2009) are primarily low-income and uninsured; 68% are below 125% of the federal poverty level and 92% are below 200%. 35% of children and 94% of adults are uninsured. ANHSI’s overall patient uninsured rate is more than twice the national uninsured rate for all patients receiving care at community health centers, which is 38 percent. 97% of ANHSI patients are members of minority groups.


b. How did the collaboration begin?

Arlandria Health Center patients are unable to access or pay for private dental care; accessible and affordable dental care was not an option for these families. We needed to find an alternative that would serve these patients and that it would be sustainable for us. Initial discussions regarding collaboration to expand primary dental care services took place between the Alexandria Health Department Director and ANHSI’s Executive Director and between Arlington County’s Public Health Division Chief and ANHSI’s Executive Director.

Once overall collaboration issues were discussed and resolved, agency program management was delegated to a shared arrangement between ANHSI’s Executive Director and the corresponding Directors of clinical service at each Health Department, in Arlington the Bureau Chief, Family Health Services and in Alexandria, the Nurse Manager. Both of these individuals defer any final decisions until the Dental Directors of each site had approved.

c. Management structure: The management structure is purposefully simple and straightforward to allow for immediate solutions to any issues that may arise. Meetings are held quarterly to review program outcomes and to plan for any required changes. The three essential staff involved in program management have open and accessible communications and equal commitment to the success of the collaboration assures smooth operations. (See Three Pillars of Collaboration discussed in the last question).

d. Challenges encountered: The major techniques to address the few challenges we have encountered are open communications and ANHSI’s willingness to respond quickly and favorably to requests from both Alexandria and Arlington. We arrived (and will continue to arrive) at solutions through a process of negotiation in which ANHSI is willing to concede to requests from both Arlington and Alexandria in light of their generous donation of space, equipment and staff support. When issues arise, a meeting is arranged promptly and through open communications, solutions are developed jointly and implemented by the appropriate person. Additionally, ANHSI has designated an administrative liaison for each site, so that any urgent problems that arise can be addressed immediately.

e. Benefits of collaboration: The primary desired and achieved outcome at both dental sites is increased access to primary and preventive oral health care for low income uninsured adults and children in Alexandria, Arlington and surrounding communities. This dental program collaboration has enabled the partners to provide care above and beyond what either Health Department is able to deliver and what ANHSI might deliver on its own. In the process of providing dental care, ANHSI has determined the need for additional services, especially for specialty care such as endodontics, crowns and prosthetics.

ANHSI is currently negotiating with both Health Departments for additional chair time in exchange for ANHSI’s donating newly acquired federal funds (requested and approved for this purpose) to install new chairs and equipment. ANHSI dentists work alongside both Arlington and Alexandria dentists, consulting with one another and sharing equipment and expertise. In Arlington, both our dentist and dental assistant are bilingual in Enlgish and in Spanish.

In Alexandria, ANHSI’s dental assistant is the only staff member in the dental clinic who speaks Spanish, and she is called on frequently to translate for patients being seen by Health Department staff. Frequently patients seeking care at both Health Departments who are not eligible for care are referred to ANHSI dentists for care.

Concrete Benefits: 5,217 dental visits through June 30, 2010; 3,555 dental patients received services. ALL Patients Have Been Uninsured.

Value of In-kind Donations by both Arlington County and the City of Alexandria assessed at $37,592 per year.
Grant contribution from a private foundation in the amount of $104,453.

f. How have the participants been able to achieve more through collaboration than they would have individually?

As public health departments, both Alexandria and Arlington County are committed to assuring access to primary care, including dental care. While each jurisdiction provides basic dental care for children and seniors, neither sees adults, except to perform emergency extractions. Each jurisdiction does not have sufficient funding to attend to the oral health needs of all low income, uninsured adults and children.

Health Department management staff recognized that operatories were underutilized and saw the opportunity to expand services by collaborating with ANHSI. ANHSI has been providing dental staff and supplies, which neither health department could afford, and the health departments supplied the operatory, waiting area, and reception staff assistance which was not in ANSHI’s budget.

The health departments are now better able to meet their mandate to assure care and ANHSI is able to care for patients needing preventive and restorative dental services. Each of us working on our own would not have been able to provide care for 3,555 patients and held 5,217 dental visits over the span of our six-year collaboration.

g. How has the success of the collaboration been measured?

Monthly, quarterly and yearly data is collected and analyzed. The growth in the number of dental patients seen and dental visits held over the past few years is indicative of the success of the program. ANHSI’s Dental Program Logic Chart and Evaluation Plan discussed in Question 1 assist in documenting and measuring outcomes. See also on 1.a. above.

The Patient Satisfaction Survey is an invaluable tool to assess continuing needs and the huge demand for dental care among our patients. Patients report that they are satisfied with the services and the dental staff; however, they are requesting an increase in available dental appointments. The Agency Partners Survey is another tool used to measure satisfaction with the collaboration and to make recommendations for program improvements. Both survey results (most recently conducted in September 2010) continue to reveal a successful dental program regarding patient access to care and our dental program collaboration goal.


h. Why should this collaboration win The Collaboration Prize?

ANHSI’s Dental Program Collaboration was built and is maintained on
Three Pillars for Success:

1) Commitment to address the serious lack of access to oral health care for low-income, uninsured children and adults;

2)Trust among agency leaders that resulted from careful and thorough negotiations and memoranda of agreement that clearly spelled out the parameters of the collaborative effort; and

3) Open and direct communication between agencies. It has persisted over six years with few challenges and those that have come up have been dealt with quickly and effectively.

This collaboration has spawned similar agreements. Having learned of this model of expanded access to dental care from ANHSI, Loudoun Community Health Center (Leesburg, VA) replicated an adapted version in Loudoun County, placing health center dentists and assistants in operatories “borrowed” from the County health department during evening hours when they were not in use.

This Dental Program Collaboration model offers a replicable alternative for others to implement anywhere in the country to meet the serious challenge of access to dental care for low-income and uninsured families with the additional benefits of preventing and improving not only oral health but overall individual health status.










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