1

Survey of Knowledge of Stakeholders in Oral Healthcare for the Elderly

Authors Tim Hung, degrees Pre-doctoral Student University of Michigan School of Dentistry timhung@umich.edu Marita R. Inglehart, Dr. phil. habil. Associate Professor University of Michigan School of Dentistry mri@umich.edu Elisa M. Ghezzi, DDS, PhD Adjunct Clinical Assistant Professor University of Michigan School of Dentistry eghezzi@umich.edu

2 Abstract Stakeholders in oral healthcare for the elderly have various backgrounds (dentistry, aging, and government). Collaboration between these three fields of professionals requires a common background of knowledge. The aim of this survey was to provide an evaluation of the level of stakeholders knowledge of programs and resources that impact access and funding for oral health care for the elderly. An online survey was completed by 37 respondents (21 dentistry, 10 aging, 6 government) with a response rate of 50%. Descriptive statistics were reported. Results demonstrate tremendous variation among professional fields regarding knowledge and involvement in existing programs, policies, and agencies. Stakeholders from all three professional fields need first to be educated and familiarized with existing programs and resources in order to effectively collaborate to improve access to oral healthcare for the elderly.

3 Introduction: In the state of Michigan, stakeholders in the oral healthcare for the aging have never convened to address the issues impacting the lack of oral healthcare for the elderly, to determine potential models of dental care for the aging, or to identify resources and funding to provide such care. Comprehensive oral healthcare for the elderly is distinct from other areas of oral healthcare due to multiple locations of care (e.g., private practice, long term care facilities, federally qualified health centers, private homes), expanded educational needs of oral healthcare providers, intervention by the health care team to identify problems and provide referrals for care, and collaboration required to secure care and assist with logistical barriers (e.g., scheduling, transportation, funding). Hence, the delivery of oral healthcare to the elderly requires a comprehensive health care team working together, which differs from a typical dental care model where the interaction is typically only between a patient and a dental care team. Since 2006, the Coalition for Oral Health for the Aging (COHA) has networked with stakeholders, advocating the importance of oral healthcare for the elderly, especially for those currently unable to access care. Funding has been dedicated by Delta Dental Foundation to convene a stakeholders meeting to discuss access to care and potential resources and funding mechanisms to provide oral healthcare for the elderly in the state of Michigan. An independent consultant has been hired to moderate the meeting and to develop a white paper from the proceedings of the meeting. Given the various backgrounds (dental, aging, and governmental) of the stakeholders who will attend the meeting, each stakeholders level of understanding of relevant issues, resources, and practice models is likely to be varied. Before productive discussion can proceed, stakeholders must have common background of knowledge. Therefore, an online anonymous survey has been conducted, via UM.Lessons., to determine the level of knowledge each stakeholder has on selected

4 programs, policies, and agencies. The aim of this survey was to provide an evaluation of the level of stakeholders knowledge of programs and resources that impact access and funding to oral health care for the elderly. The results of this survey will be used to determine critical preliminary background materials and presentations necessary for constructive dialogue.

Method: This study was approved by the Institutional Review Board for the Health and Behavioral Sciences at the University of Michigan, Ann Arbor, Michigan. Respondents: Stakeholders in providing care for older adults in the state of Michigan who had previous interest or involvement in programs addressing access to oral healthcare for the elderly were identified in the fields of dentistry, aging, and government. These included persons from academic institutions, insurance companies, professional organizations, clinical practice, governmental departments, and for- and not-for-profit agencies. These seventy-four individuals were contacted by email and asked to respond to a survey. A total of 45 stakeholders responded to the survey. However, among the 45 stakeholders who took the survey, only 37 completed the entire survey with valid answers (Response rate: 50%). These respondents selfidentified as being in the field of dentistry (N=21), aging (N=10), or government (N=6). Of the 21 dental professionals, 14 self-identified as having a dental degree and 12 as having a dental hygiene degree or being a registered dental hygienist. Procedure: The survey was uploaded to a University of Michigan website used to collect survey data in a safe and anonymous fashion. The respondents received recruitment emails in which they were informed about the study and asked to volunteer to connect with the survey on

5 the website through a web link that was provided in the email. A follow up second email was sent out approximately 2 weeks later. Materials: The survey consisted of three parts. Part 1 asked the respondents for some background information about their primary professional fields. Part 2 consisted of asking the respondents (a) how much they knew about each of 16 programs that focus on oral health care for older adults in the state of Michigan and nationwide, and (b) how involved they personally were/are with each of these 16 programs. Answers concerning their knowledge were provided on a 5 point rating scale ranging from 1 = I had known nothing to 5 = I had known everything mentioned in the description about this program. Answers to the second question consisted of the categories I am currently involved with this program, I am not currently involved with this program, but I have been involved with this program in the past, and I have never been involved with this program. Part 3 consisted of general questions concerning the respondents opinions regarding access to oral healthcare for the elderly in Michigan and their perceptions of barriers to care. Statistical analyses: The data were analyzed with SPSS 19. Descriptive statistics were computed such as frequencies and percentages to provide an overview of the findings.

Results: Dentistry Category (See Figure 1) Michigan Community Dental Clinics, Inc. Table 1 indicates that stakeholders in the aging field have limited knowledge about Michigan Community Dental Clinics, Inc. (MCDC) while the surveyed dental stakeholders have some knowledge, and governmental stakeholders have significant knowledge about this public

6 health service. Table 2, however, demonstrates that most stakeholders have never been involved with this service regardless of their professional backgrounds. Apple Tree Dental Stakeholders in the dental field are highly knowledgeable about Apple Tree Dental model from Minnesota. Stakeholders in the aging field only have limited knowledge, and those in the government have some knowledge about this model. There is no involvement with this model from any of the three professional fields in Michigan currently. Dental Therapist Model Table 1 clearly demonstrates that surveyed stakeholders in dentistry and in the government are keenly aware of the dental therapist model while those in the aging field have only limited knowledge about it. Table 2 indicates that over 80% of surveyed stakeholders have never been involved with any kind of dental therapist model. Dentistry + Government Category (See Figure 1) Michigan Department of Community Health Oral Health Division Although stakeholders in the dental and governmental fields are highly knowledgeable about this division, those in the aging field are significantly unaware of it. While 57% of surveyed dental stakeholders and 83% of governmental stakeholders have been or are currently involved, none of the surveyed aging stakeholders have been involved with this division. Michigan Oral Health Coalition (MOHC) Table 1 indicates that all survey respondents are quite aware of this government-funded dental public health coalition. While half of the surveyed dental stakeholders and all of the surveyed governmental stakeholders have been or are currently involved with this organization, 70% of aging stakeholders have never been involved with it, as shown in Table 2.

7 Healthy Kids Dental As shown in Tables 1 and 2, most of the survey correspondents working in governmental offices are not only decently knowledgeable about the Healthy Kids Dental Program but also highly involved with this program. Stakeholders in dentistry are fairly aware of this program, but less than half of these stakeholders either have participated or are currently participating in this program. Stakeholders working in the aging field only have limited knowledge about it and are only minimally involved with the program. Public Act 161 of 2005 Tables 1 and 2 show that most stakeholders are decently aware of Public Act 161 of 2005. Over 80% of the governmental stakeholders and about half of the surveyed dental professionals have participated or are currently involved with a Public Act 161 program while only 10% surveyed stakeholders working in the aging field are involved with any Public Act 161 program. Aging + Government category (See Figure 1) Area Agencies on Aging (AAA) Tables 1 and 2 demonstrate that although all surveyed participants are highly knowledgeable about Area Agencies on Aging, only stakeholders in the aging field are significantly involved with AAA. Michigan Office of Services to the Aging (OSA) Tables 1 indicates that although surveyed stakeholders in aging are keenly aware of OSA, those in dentistry have very limited knowledge about it. Although OSA is a governmental branch, the surveyed stakeholders in the government only have some knowledge about OSA. Table 2 shows a similar trendwhile 90% of stakeholders in aging and 50% in the government

8 have been or are currently involved, only 10% of those in dentistry have been involved with OSA. Dentistry + Aging category (See Figure 1) Coalition for Oral Health for the Aging (COHA) Table 1 demonstrates that all survey stakeholders are quite knowledgeable about this organization, and Table 2 indicates that about 60% of all survey participants either have been or are currently involved with this organization. Dental Days The data indicates that while stakeholders in aging and government are significantly aware, those in dentistry have limited knowledge about Dental Days. 50% of those in the aging field are currently participating with the program, but over 80% of those in dentistry or in the government have never been involved with it. Aleydis Centers Surveyed stakeholders in all three professions have some knowledge about the Aleydis Centers model. However, Table 2 indicates that 30% of the surveyed stakeholders in the aging field are currently involved with it while none of those in dentistry or in the government are involved with this model. Dentistry + Aging + Government category (See Figure 1) Medicare The data indicate that all surveyed stakeholders are highly knowledgeable about the lack of Medicare coverage for dental care. Incurred Medical Expense (IME)

9 Incurred Medical Expense (IME) is the ability to pay for dental care above and beyond Medicaid dental coverage. Surveyed dental professionals are decently knowledgeable, but governmental professionals only have some knowledge, and those in the aging field have only limited knowledge about IME. Table 2 further demonstrates that very few (30% or less) of all surveyed stakeholders either have been involved or are currently involved with IME. Senate Bill 747 of 2012 and House Bill No. 5951 of 2012 The data indicate that among surveyed stakeholders, only those in the government are highly aware of either bill of 2012. Although both bills have tremendous impact on the oral care of the elderly, stakeholders in dentistry and in aging have limited knowledge about them. Over 70% of all survey respondents have never been involved with S.B.747 of 2012. 66% of governmental, 40% of dental, and 20% of aging stakeholders were involved with H.B. No.5951 of 2012. Barriers to Care Most respondents agree that access to oral healthcare is a right of the elderly in Michigan. Lack of finances, lack of transportation, lack of perceived need, lack of trained providers, lack of providers willing to take Medicaid reimbursement, and no equipment or space available for care in long term care facilities are defined as barriers to care by over 90% of all respondents. Discussion: In addressing access-to-oral healthcare issues for the elderly in the state of Michigan, the process of facilitating the establishment of oral healthcare models with appropriate funding mechanisms includes two distinct stages: the educational stage and the collaborative stage. Stakeholders from all three professional fieldsdentistry, aging, and governmentneed first to be educated and familiarized with existing potential models and resources that can be efficiently

10 utilized. After the stakeholders have gained adequate knowledge regarding the relevant policies, programs, and agencies, participation and collaboration between all three fields of professionals should be advocated and encouraged. The data collected from the survey demonstrate there is a lack of understanding and the awareness among the stakeholders of the majority of programs, policies, and agencies. Few programs and agencies are ready to be considered in the collaborative stage without further education and knowledge. Dentistry categoryMichigan Community Dental Clinics, Inc., Apple Tree Dental, Dental Therapists Model When designing a comprehensive oral healthcare delivery model for the elderly, there are existing resources and working models available for stakeholders to replicate. Michigan Community Dental Clinics, Inc. is a successful model in the state of Michigan for those with limited funds. Apple Tree Dental is expanding beyond Minnesota to provide mobile dental care to those unable to access care in the clinical office setting. Many states are considering a Dental Therapist Model of care to provide oral healthcare services to those unable to access care in traditional private practice settings due to lack of proximity or funding for care. These nationally recognized models are critical to consider. However, from the results of this survey, education of stakeholders regarding these models is required to facilitate discussion of feasibility and costeffectiveness of these existing models. Michigan currently does not have a model of care providing oral healthcare to the indigent unable to be seen in a clinical office setting. Successful collaboration to support models of oral healthcare for the elderly requires significant investigation of existing models to establish a sustainable model with effective reimbursement and funding mechanisms.

11 Dentistry + Government CategoryMichigan Department of Community Health Oral Health Division, Michigan Oral Health Coalition, Healthy Kids Dental, Public Act 161 of 2005 Dentistry has collaborated with government agencies to establish programs to promote oral healthcare in the state of Michigan. These programs have been quite successful in addressing access to care, particularly for the children in the state of Michigan. However, since there is minimal outreach to the elderly, there is a lack of awareness and involvement from the aging stakeholders. The Michigan Department of Community Health Oral Health Division has focused much of their efforts on programs designed for childrens dental needs (e.g., sealant programs, fluoride varnish programs, Healthy Kids Dental). It is anticipated that collaboration between the oral health division and aging organizations will increase as MDCHOHD expands its involvement in aging with grant funding and projects impacting oral healthcare for the elderly. Collaboration between state oral health programs and aging organizations is critical and should be supported with state and federal funding. Similarly, the Michigan Oral Health Coalition, like many state oral health coalitions, is a dental public health coalition whose projects often promote oral heathcare for children (e.g., sealant programs, water fluoridation programs, Healthy Kids Dental). State oral health coalitions are critical stakeholders and collaborators in oral healthcare for the aging. However, given limited funds and priorities which are typically focused on childrens oral health, it may be necessary for states to have distinct oral health coalitions that focus on the oral healthcare for the aging, such as Michigans Coalition for Oral Health for the Aging. The Healthy Kids Dental program is a nationally recognized reimbursement model for children eligible for Medicaid in the state of Michigan. Because it is designed to increase

12 reimbursement levels higher than standard Medicaid reimbursement, it has resulted in more oral healthcare providers treating indigent children. It is important for stakeholders to understand this program as replication of this model for elderly eligible for Medicaid could establish a feasible funding mechanism for the oral health care for the elderly. Significant legislative support would be required by all stakeholders to accomplish this goal. Although most surveyed stakeholders are aware of Public Act 161 of 2005 further defining collaborative practice in the state of Michigan, the majority of the existing programs focus on providing oral healthcare such as sealants and fluoride varnish to children. This trend in collaborative practice is replicated across the country. Because the majority of oral healthcare needs of dentate residents in the long term care facilities are preventive services that can be provided by dental hygienists, the expansion of Public Act 161 programs and collaborative practices in these settings are imperative for adequate access to oral healthcare for this population. A collaborative effort from the aging, dentistry, and government stakeholders to increase the participation and involvement with Public Act 161 programs in provision of oral healthcare for the elderly is critical for improving access to care. Partners in the aging field can play a critical role in the identification of funding mechanisms as well as patient populations and facilities interested in working with a Public Act 16 program. Aging + Government categoryArea Agencies on Aging, Office of Services to the Aging The survey results demonstrate stakeholders outside the aging field need to become more aware and more involved with agencies established for the seniors at both the local and federal level. The aging agencies are critical players in the identification of resources and the implementation of programs. Professionals in the aging field can facilitate and encourage long

13 term care facilities to become partners in delivering oral healthcare care to residents. An example of collaboration is a local Area Agency on Aging assisting in identifying long term care facilities interested in having a trained registered dental hygienist educate the care staff about the importance of oral health. The collaboration between all three professional fields needs to be established to capitalize on each groups resources and connections to provide comprehensive oral care to the aging population. Dentistry + Aging categoryCoalition for Oral Health for the Aging, Dental Days, Aleydis Centers The survey results clearly indicate a need for the cross-professional collaboration to address the oral health needs of the elderly. The Coalition for Oral Health for the Aging provides a platform for the facilitation of effective conversation and networking opportunities between the professionals from aging, dentistry, and government. As previously discussed, state oral health coalitions typically have multiple priorities ranging from sealant and fluoride varnish programs in children to tobacco cessation and water fluoridation. There is a need for state and national level interdisciplinary coalitions to specifically address the oral health needs of the elderly. The goals of a Coalition for Oral Health for the Aging should be to be a resource for providers of care for the aging, to promote the implementation of policies that support evidence based strategies that provide optimal oral health for the aging, and to develop collaborative partnerships that address the oral health needs of the aging. This mission to improve the oral health of older people is accomplished through advocacy, professional education, public education, and research by focusing on prevention, health promotion, and evidence-based practices. Dental Days are an example of a collaborative effort between stakeholders, Area Agencies on Aging and the Coalition for Oral Health for the Aging, utilizing a Public Act 161

14 program. The aging organization providing patient recruitment, transportation, and referral facilitation capitalizes on their resources which are limited in the field of dentistry. Likewise, the provision of care by the dental professionals capitalizes on dentistrys role in the collaboration. Identification of each stakeholders resources and abilities is critical in successful collaboration. An Aleydis Center is a multi-function treatment center located in long-term care facilities where oral health care services are provided in a private practice environment. This is a unique model for provision of care and improvement of access to care within the communities served by the aging organizations. Continued collaboration between the aging and dental professionals is required to secure its success in identification of funding to maintain the center and the recruitment of health care providers and patients. Dentistry + Aging + Government categoryMedicare, Incurred Medical Expense, Senate Bill 747 of 2012 and House Bill 5951 of 2012 (currently House Bill 4865 of 2013) The survey data clearly demonstrate that stakeholders are aware that Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Most elderly adults do not have insurance coverage and need to pay out of pocket for dental services. Therefore, the need for funding sources for oral healthcare for the aging is recognized by stakeholders. Incurred Medical Expense (IME) reimbursement is available in all states and is most useful in states that do not have adult Medicaid dental coverage as it establishes a mechanism for the adult Medicaid population residing in nursing home facilities to obtain funds for oral healthcare. In states such as Michigan which currently has adult Medicaid coverage for exams, 2 cleanings per year, x-rays, fillings, and removable dentures, IME can only be used to reimburse for procedures not covered by Medicaid such as crowns, bridges, and additional cleanings

15 beyond the two covered by Medicaid. To submit required paperwork significant administrative burden and collaboration of the dental professionals, long term care facility administrative staff, and governmental agencies is necessary. The survey results regarding Senate Bill 747 of 2012 and House Bill 5951 of 2012 (currently House Bill 4865 of 2013) demonstrate a lack of understanding and awareness among dental and aging professionals of proposed legislation that can significantly impact their professional fields. Mechanisms to educate stakeholders on pertinent legislation need to be developed. Senate Bill 747 of 2012 is proposed legislation requiring nursing home and assisted living facilities to provide medical and dental care in a private examination room solely dedicated to these services it has financial implications for facilities and logistical care delivery limitations for oral healthcare providers. Regulation of mobile dentistry through Michigan House Bill 4865 of 2013 establishes limits on oral healthcare delivery of Public Act 161 programs and on the provision of oral health care in long-term care facilities. Stakeholders should not only be knowledgeable about the impact of proposed legislation on oral healthcare for the aging, collaboration can facilitate coordinated lobbying efforts to enhance oral healthcare for this population as well as preventing regulations that inhibit care delivery. Barriers to Care and Resources Identification of and consensus regarding the challenges has been reached as all stakeholders agree on barriers to oral healthcare for the aging. Moving forward with solutions to these barriers requires education regarding existing resources and programs defined in this study as well as others recommended by respondents. It is recommended that stakeholders be knowledgeable of training programs for providers of oral healthcare for the aging and challenges regarding recruitment of participants and funding. Other resources to consider include Program

16 of All-Inclusive Care for the Elderly (PACE), Oral Health America Tooth Wisdom Project, Geriatric Education Centers, Federally Qualified Health Centers Dental Services, and Donated Dental Services. Conclusion: The survey results demonstrate a need for a stakeholders meeting to consider costeffective oral healthcare models for the elderly in the State of Michigan as well as providing evidence that stakeholders from different professional fields possess varying levels of understanding about the existing resources and programs. Many of these resources are currently not fully utilized due to a lack of stakeholders knowledge and to minimal existing collaboration between the aging, the dental, and the government professionals. Addressing this educational gap is critical for stakeholders to move forward with productive conversation and dialogue to enhance oral healthcare delivery to the elderly. Such productive dialogue is beneficial to facilitate networking and the formation of collaborative projects and initiatives.

17 Appendix A: Figures and Tables Figure 1: Professional fields each policy/program/agency is related to.

Den stry: MCDC Apple Tree Dental Dental Therapists Den stry + Government: MDCHOHD MOHC Healthy Kids P.A. 161 of 2005 Den stry + Aging + Government: Medicare IME S.B. 747 of 2012 H.B. 5951 of 2012

Den stry + Aging: COHA Dental Days Aleydis Centers

Government

Aging

Aging + Government: OSA AAA

18 Table 1: Average responses of respondents with education in dentistry, aging vs. government concerning their knowledge about the different programs. Program/Policy MCDC Apple Tree Dental Dental therapists MDCHOHD MOHC Healthy Kids PA 161 AAA OSA COHA Dental Days Aleydis Centers Medicare IME S.B. 747 of 2012 H.B. No. 5951 of 2012 Dentistry N =21 3.24 4.24 4.76 4.24 4.19 3.76 4.33 4.05 2.67 3.95 2.95 3.00 4.91 4.38 3.19 3.14 Aging N = 10 2.80 2.10 2.80 1.90 3.50 2.40 4.10 4.90 4.70 3.90 4.00 2.60 4.90 2.90 2.70 2.40 Government N=6 4.50 3.33 4.67 4.33 5.00 4.50 4.67 4.00 3.33 4.67 4.17 3.50 5.00 3.33 4.00 4.67 pvalue .133 .001 .000 .000 .095 .024 .700 .172 .001 .479 .111 .655 .745 .004 .357 .037

Legend: 1 The answers ranged from 1 = know nothing to 5 = know everything in The description of the program. 2 Interpretation of the values in Table 1: > 4: significantly knowledgeable/ largely aware 3-4: have some knowledge/ fairly aware 2-3: limited knowledge < 2: minimal knowledge/ significantly unaware

19 Table 2: Overview of the types of involvement with different organizations by type of educational background. Program Involvement: MCDC None In past Now Apple Tree Dental None In past Now Dental therapists None In past Now MDCHOHD None In past Now MOHC None In past Now Healthy Kids None In past Now PA 161 None In past Now AAA None In past Now OSA None In past Now Dentistry Aging Government Contingency coefficient

16 (76.2%) 3 (14.3%) 2 (9.5%) 17 (81.0%) 2 (9.5%) 2 (9.5%) 18 (85.7%) 2 (9.5%) 1 (4.8%) 9 (42.9%) 4 (19.0%) 8 (38.1%) 10 (50.0%) 3 (15.0%) 7 (35.0%) 12 (57.1%) 4 (19.0%) 5 (23.8%) 11 (52.4%) 5 (23.8%) 5 (23.8%) 10 (47.6%) 7 (33.3%) 4 (19.0%) 19 (90.5%) 0 (0.0%) 2 (9.5%)

8 (80.0%) 1 (10.0%) 1 (10.0%) 10 (100.0%) 0 (0.0%) 0 (0.0%) 9 (90.0%) 0 (0.0%) 1 (10.0%) 10 (100.0%) 0 (0.0%) 0 (0.0%) 7 (70.0%) 1 (10.0%) 2 (20.0%) 7 (70.0%) 1 (10.0%) 2 (20.0%) 9 (90.0%) 0 (0.0%) 1 (10.0%) 0 (0.0%) 1 (10.0%) 9 (90.0%) 1 (10.0%) 2 (20.0%) 7 (70.0%)

4 (66.7%) 1 (16.7%) 1 (16.7%) 6 (100.0%) 0 (0.0%) 0 (0.0%) 5 (83.3%) 0 (0.0%) 1 (16.7%) 1 (16.7%) 0 (0.0%) 5 (83.3%) 0 (0.0%) 0 (0.0%) 6 (100.0%) 1(16.7%) 0 (0.0%) 5 (83.3%) 1 (16.7%) 2 (33.3%) 3 (50.0%) 3 (50.0%) 2 (33.3%) 1 (16.7%) 3 (50.0%) 1 (16.7%) 2 (33.3%)

.111 P = .977

.291 P = .491

.248 P = .659

.556 P = .002

.486 P = .025

.446 P =.057

.442 P = .061

.551 P = .003

.588 P = .001

20 Program Involvement: COHA None In past Now Dental Days None In past Now Aleydis Centers None In past Now Medicare None In past Now IME None In past Now S.B. 747 of 2012 None In past Now H.B. 5951 of 2012 None In past Now Dentistry Aging
Government

Contingency coefficient .303 P = .444

9 (42.9%) 1 (4.8%) 11 (52.4%) 17 (81.0%) 2 (9.5%) 2 (9.5%) 20 (95.2%) 1 (4.8%) 0 (0.0%) 10 (47.6%) 5 (23.8%) 6 (28.6%) 15 (71.4%) 5 (23.8%) 1 (4.8%) 15 (71.4%) 2 (9.5%) 4 (19.0%) 12 (57.1%) 1 (4.8%) 8 (38.1%)

2 (20.0%) 2 (20.0%) 6 (60.0%) 5 (50.0%) 0 (0.0%) 5 (50.0%) 7 (70.0%) 0 (0.0%) 3 (30.0%) 4 (40.0%) 1 (10.0%) 5 (50.0%) 7 (70.0%) 1 (10.0%) 2 (20.0%) 7 (70.0%) 2 (20.0%) 1 (10.0%) 8 (80.0%) 2 (20.0%) 0 (0.0%)

2 (33.3%) 0 (0.0%) 4 (66.7%) 5 (83.3%) 1 (16.7%) 0 (0.0%) 6 (100.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (33.3%) 4 (66.7%) 5 (83.3%) 0 (0.0%) 1 (16.7%) 5 (83.3%) 1 (16.7%) 0 (0.0%) 2 (33.3%) 1 (16.7%) 3 (50.0%)

.454 P = .047

.451 P = .051

.369 P = .212

.303 P = .441

.231 P = .720

.408 P = .116

21 Appendix B: Questions on the Survey 1. Let us start with some general background questions. What is your primary occupation title or your professional role? Please click on the blue disc icon to save your answer. 2. What is your primary occupational or professional field? Aging, Dentistry, Government, Other 3. Please list your educational degree(s). 4. The Healthy Kids Dental Program is a program where the Michigan Department of Community Health contracts with Delta Dental to provide dental benefits to Medicaid-eligible residents under the age of 21 who live in 75 Michigan counties. The reimbursement rates for services in this program are higher than the typical Medicaid reimbursement rates for this population. Before reading this description, I had known 1 = nothing mentioned in the description above about this program. 2 3 4 5 = everything mentioned in the description above about this program. 5. Please tell us if you are currently involved or have been involved with this program in the past. I am currently involved with this program. I am not currently involved with this program, but I have been involved with this program in the past. I have never been involved wit this program. 6. For dental insurance options for oral health care for elderly adults in the state of Michigan, some have retiree insurance from the previous employment. Medicare does NOT cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Most elderly adults do not have insurance coverage and need to pay out of pocket for dental services. Before reading this description, I had known 1 = nothing mentioned in the description above about Medicare. 2 3 4 5 = everything mentioned in the description above about Medicare. 7. Please tell us if you are currently involved or have been involved with Medicare in the past. I am currently involved with this program. I am not currently involved with this program, but I have been involved with this program in the past. I have never been involved wit this program.

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8. Public Act 161 of 2005 is legislation whereby a dental hygienist may perform dental hygiene services under the supervision of a dentist as part of a program for dentally underserved populations, such as nursing home residents, for patients who are not assigned by a dentist. Before reading this description, I had known 1 = nothing mentioned in the description above about this legislation. 2 3 4 5 = everything mentioned in the description above about this legislation. 9. Please tell us if you are currently involved or have been involved with a PA 161 program in the past. I am currently involved with a PA 161 program. I am not currently involved with a PA 161 program, but I have been involved with a PA 161 program in the past. I have never been involved with a PA 161 program. 10. Incurred Medical Expense can help nursing facility residents who are enrolled in Medicaid pay for dental care. Medicaid residents with Social Security or other retirement income may be able to pay for medically necessary dental care that is not covered by Medicaid. Before reading this description, I had known 1 = nothing mentioned in the description above about Incurred Medical Expense. 2 3 4 5 = everything mentioned in the description above about Incurred Medical Expense. 11. Please tell us if you are currently involved or have been involved with Incurred Medical Expense in the past. I am currently involved with Incurred Medical Expense. I am not currently involved with Incurred Medical Expense, but I have been involved with Incurred Medical Expense in the past. I have never been involved with Incurred Medical Expense. 12. Michigan Community Dental Clinics, Inc. (MCDC) is a not-for-profit management services corporation, established in 2006, to allow the Dental Clinics North (DCN) model for delivery of public health dental services. The target populations served by the clinics are adults and children on Medicaid, as well as low income, uninsured individuals whose income is below 200% of the Federal poverty level. Non-Medicaid clients are offered a reduced fee schedule. Before reading this description, I had known 1 = nothing mentioned in the description above about the Michigan Community Dental Clinics, Inc. model of care in the State of Michigan. 2 3 4

23 5 = everything mentioned in the description above about the Michigan Community Dental Clinics, Inc. model of care in the State of Michigan. 13. Please tell us if you are currently involved or have been involved with the Michigan Community Dental Clinics, Inc. model of care in the past. I am currently involved with Michigan Community Dental Clinics, Inc. I am not currently involved with Michigan Community Dental Clinics, Inc., but I have been involved with Michigan Community Dental Clinics, Inc. in the past. I have never been involved with Michigan Community Dental Clinics, Inc. 14. Apple Tree is a nonprofit dental organization established in Minnesota with support from individual donors, foundation grants, and corporate sponsors. The mobile delivery programs set up as full-scale dental offices in schools and nursing facilities, providing comprehensive dental services to their populations. Before reading this description, I had known 1 = nothing mentioned in the description above about Apple Tree Dental model from Minnesota. 2 3 4 5 = everything mentioned in the description above about Apple Tree Dental model from Minnesota. 15. Please tell us if you are currently involved or have been involved with Apple Tree Dental in the past. I am currently involved with this program. I am not currently involved with this program, but I have been involved with this program in the past. I have never been involved wit this program. 16. The Michigan Oral Health Coalition is comprised of primary care clinicians, oral health clinicians, dental benefit providers, advocacy and provider organizations, state and local government officials, and consumers working together to improve oral health in Michigan. Its mission is to improve oral health in Michigan by focusing on prevention, health promotion, oral health data, access and the link between oral health and overall health. Before reading this description, I had known 1 = nothing mentioned in the description above about this organization. 2 3 4 5 = everything mentioned in the description above about this organization. 17. Please tell us if you are currently involved or have been involved with Michigan Oral Health Coalition in the past. I am currently involved with Michigan Oral Health Coalition. I am not currently involved, but I have been involved with Michigan Oral Health Coalition in the past. I have never been involved with Michigan Oral Health Coalition.

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18. The Michigan Coalition for Oral Health for the Aging's (COHA) mission is to improve the oral health of older people through advocacy, professional education, public education, and research by focusing on prevention, health promotion, and evidence-based practices. COHA's goals are to be a resource for providers of care for the aging and special needs populations, to promote the implementation of policies that support evidence based strategies that provide optimal oral health for the aging, and to develop collaborative partnerships that address the oral health needs of the aging and special needs populations. Before reading this description, I had known 1 = nothing mentioned in the description above about this organization. 2 3 4 5 = everything mentioned in the description above about this organization. 19. Please tell us if you are currently involved or have been involved with this organization in the past. I am currently involved with this organization. I am not currently involved with this organization, but I have been involved with this organization in the past. I have never been involved with this organization. 20. The Michigan Department of Community Health Oral Health Division provides consultation, technical assistance, and program coordination on many oral health programs and issues, such as school sealants and fluorides. Before reading this description, I had known 1 = nothing mentioned in the description above about the Michigan Department of Community Health Oral Health Division. 2 3 4 5 = everything mentioned in the description above about the Michigan Department of Community Health Oral Health Division. 21. Please tell us if you are currently involved or have been involved with the Michigan Department of Community Health Oral Health Division in the past. I am currently involved with the Michigan Department of Community Health Oral Health Division. I am not currently involved with the Michigan Department of Community Health Oral Health Division, but I have been involved with the Michigan Department of Community Health Oral Health Division in the past. I have never been involved with the Michigan Department of Community Health Oral Health Division. 22. Area Agencies on Aging were established under the Older Americans Act (OAA) in 1973 to respond to the needs of Americans aged 60 and over in every local community. There are 16 area agencies serving the state of Michigan. AAA advocates on issues of concern to older adults,

25 persons with disabilities and family caregivers. AAA also allocates and administers federal, state and private funds to support home and community-based services (such as Meals on Wheels for Seniors). Before reading this description, I had known 1 = nothing mentioned in the description above about Area Agencies on Aging. 2 3 4 5 = everything mentioned in the description above about Area Agencies on Aging. 23. Please tell us if you are currently involved or have been involved with Area Agencies on Aging in the past. I am currently involved with Area Agencies on Aging. I am not currently involved, but I have been involved with Area Agencies on Aging in the past. I have never been involved with Area Agencies on Aging. 24. The Michigan Office of Services to the Aging (OSA) advocates on behalf of adults age 60 and over and caregivers for policies, programs, and services. OSA funded programs include care management, caregiver services, community-based services, elder abuse prevention services, inhome services, legal assistance program, Medicare/Medicaid assistance program, congregate meals program, and Senior Community Services Employment program. Before reading this description, I had known 1 = nothing mentioned in the description above about OSA. 2 3 4 5 = everything mentioned in the description above about OSA. 25. Please tell us if you are currently involved or have been involved with OSA in the past. I am currently involved with OSA. I am not currently involved with OSA, but I have been involved with OSA in the past. I have never been involved with OSA. 26. Area Agencies on Aging/Coalition for Oral Health for the Aging Dental Days provide preventative oral health care services for elderly through the PA 161 COHA Care program. Nonprofit organizations, such as AAA, provide patient recruitment, transportation, and referral facilitation. Before reading this description, I had known 1 = nothing mentioned in the description above about this program. 2 3 4 5 = everything mentioned in the description above about this program. 27. Please tell us if you are currently involved or have been involved with this program in the past. I am currently involved with this program.

26 I am not currently involved with this program, but I have been involved with this program in the past. I have never been involved wit this program. 28. The dental therapist model of care involves midlevel dental providers (non-dentists) performing oral health care services including surgical/irreversible procedures. To date there has been no consensus on the specific prerequisites, scope or duration of educational program, and scope of practice. Before reading this description, I had known 1 = nothing mentioned in the description above about this model of care. 2 3 4 5 = everything mentioned in the description above about this model of care. 29. Please tell us if you are currently involved or have been involved with this model of care in the past. I am currently involved with this model of care. I am not currently involved with this model of care, but I have been involved with this model of care in the past. I have never been involved with this model of care. 30. The Aleydis Centers is a multi-function treatment center located in long-term care facilities where oral health care services are provided in a private practice environment. Before reading this description, I had known 1 = nothing mentioned in the description above about Aleydis Centers. 2 3 4 5 = everything mentioned in the description above about Aleydis Centers. 31. Please tell us if you are currently involved or have been involved with Aleydis Centers in the past. I am currently involved with Aleydis Centers. I am not currently involved with Aleydis Centers, but I have been involved with Aleydis Centers in the past. I have never been involved with Aleydis Centers. 32. Senate Bill 747 of 2012 is proposed legislation requiring nursing home and assisted living facilities to provide medical and dental care in a private examination room solely dedicated to these services. Before reading this description, I had known 1 = nothing mentioned in the description above about this bill. 2 3 4 5 = everything mentioned in the description above about this bill.

27 33. Please tell us if you are currently involved or have been involved with this bill in the past. I am currently involved with this bill. I am not currently involved with this bill, but I have been involved with this bill in the past. I have never been involved with this bill. 34. House Bill No. 5951 of 2012 is coauthored by MDA and MDCH to regulate provision of mobile dentistry in Michigan, impacting PA 161 programs and provision of oral health care in long-term care facilities. Before reading this description, I had known 1 = nothing mentioned in the description above about this bill. 2 3 4 5 = everything mentioned in the description above about this bill. 35. Please tell us if you are currently involved or have been involved with this bill in the past. I am currently involved with this bill. I am not currently involved, but I have been involved with this bill in the past. I have never been involved with this bill. 36. Do you consider access to oral health care a right of the elderly in the State of Michigan? Yes No 37. If yes, to what type of oral health care should all elderly have access? (Select all that apply) If no, please select Not Applicable. Preventative care (Exam/ X-rays/ Cleaning 2-4 times per year depending on the need) Simple restorative (fillings) Complex restorative (Crowns) Denture construction Denture repair Extractions Other (Please specify) Not Applicable 38. In your opinion, what are barriers to access to oral health care for the elderly? (Select all that apply.) Lack of finances Lack of transportation Lack of perceived need Lack of trained providers Lack of providers willing to take Medicaid No equipment/ space available for care in the housing facility Other (please specify)

28 39. What other resources and programs are you aware of that impact access and funding to oral health care for the elderly that are not included in this survey? Please click the blue disc icon to save your answer.

29 Appendix C: Program Websites Apple Tree Dental: http://www.appletreedental.org/ Aleydis Centers: http://www.aleydiscenters.com/ Area Agencies on Aging Association of Michigan: http://www.mi-seniors.net/ Coalition for Oral Health for the Aging: http://www.micoha.org/ Donated Dental Services: http://www.nfdh.org/donated-dental-services-dds Federally Qualified Health Centers Dental Services
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fqhcfactsheet.pdf

Geriatric Education Centers: http://www.nagec.org/ http://gecm.msu.edu/ Healthy Kids Dental Program:

http://www.deltadentalmi.com/Individuals/Healthy-Kids-Dental-and-MIChild/Healthy-Kids-Dental.aspx http://www.michigan.gov/mdch/0,1607,7-132-2943_4845-17752--,00.html

Incurred Medical Expense: http://www.ada.org/sections/professionalResources/pdfs/ime_documents.pdf Medicare: http://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html?redirect=/MedicareDentalCoverage Michigan Community Dental Clinics, Inc. http://midental.org/ Michigan Department of Community Health Oral Health Division:
http://www.michigan.gov/mdch/0,1607,7-132-2942_4911_4912_6226---,00.html

Michigan Office of Services to the Aging: http://www.michigan.gov/osa Michigan Oral Health Coalition: http://www.mohc.org/ Michigan Public Act 161 of 2005:
http://www.legislature.mi.gov/documents/2005-2006/publicact/htm/2005-PA-0161.htm

Oral Health America: http://oralhealthamerica.org/ Program of All-Inclusive Care for the Elderly (PACE)

30
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/IntegratingCare/Program-of-All-Inclusive-Care-for-the-Elderly-PACE/Program-of-All-Inclusive-Care-for-the-Elderly-PACE.html