Spring 2015

One-Stop Health

Dentists upstairs, physicians downstairs. Integrated community clinics make it easier to care for patients—and for patients to take care of themselves

By Jacqueline Mitchell and Julie Flaherty

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Mercedes Rodriguez, her son Roberto Garcia and dental assistant Diana Duran at the Eisner Pediatric and Family Medical Center. Photos: Kelvin Ma

It’s a typical Tuesday morning at the Eisner Pediatric and Family Medical Center, a nonprofit community health center a few blocks from the arena where the Los Angeles Lakers play. Two dental assistants head downstairs from their second-floor clinic to the pediatric medicine waiting room, which is awash in sunshine pouring through the skylights in the vaulted ceilings. While 200 people, maybe more, wait to see a doctor, the dental assistants approach parents to offer them a free anticavity varnish for their kids.

Upstairs in the dental clinic waiting room is Cynthia Borbon, 29, who first visited the Eisner Center women’s health clinic a month ago, when she learned she was pregnant. Her doctors there referred her to the dental clinic for prenatal oral health care. It’s not something she realized was part of having a healthy baby, but she’s glad she can get her prenatal and dental care in the same building. It means fewer trips and less paperwork.

The availability of both medical and dental care makes Eisner a one-stop shop, saving patients time, money and hassle, all of which encourages continuity of care, says John Pham, D99, director of dental services at Eisner.

Three thousand miles away, on Boston’s bustling Blue Hill Avenue, is the Mattapan Community Health Center, which offers a similar menu of medical and dental care to an underserved urban neighborhood. Patients can receive their primary care here and see specialists in dermatology and obstetrics and gynecology, among others. They can get counseling for diabetes, HIV/AIDS and other chronic conditions and have their lab work done—all in one place. Another Tufts graduate, Betty Jean-Mary, D94, is director of dental services there.

Patients who have a “health-care home” are more successful at managing chronic diseases, such as diabetes or hypertension.

The urban health centers in L.A. and Boston are among the nation’s 1,200 Federally Qualified Health Centers (FQHC), which operate in underserved areas. The FQHCs, a designation of the Department of Health and Human Services, receive higher reimbursements from Medicare and Medicaid, among other benefits, in exchange for providing comprehensive health services. They also are required to have robust quality-
assurance programs in place.

Community health centers are not just convenient for patients. They deliver care more fairly and efficiently than the traditional health-care model, according to the National Association of Community Health Centers, an advocacy group for local health clinics and their patients. The association estimates that integrated centers like these save the U.S. health system $24 billion a year for one simple reason—people who have regular access to care are generally healthier. Patients who have a “health-care home” also are more successful at managing chronic diseases, such as diabetes or hypertension, according to the national advocacy group.

This increasingly popular model for health-care delivery—dentists, physicians, therapists and other professionals working as a team—has shown promise for the entire U.S. health-care system, regardless of patient demographics, according to Herb K. Schultz, the Eisner Center’s president and CEO.

The need to educate future health-care workers to operate in this new, collaborative environment—what is known as interprofessional education—continues to increase. Interprofessional education, or IPE, as it is known, is a cornerstone of Tufts School of Dental Medicine’s strategic plan (see go.tufts.edu/healthhome).

Team Works

Most patients at FQHCs live well below the federal poverty line, about $24,000 a year for a family of four. The chronic health conditions that often accompany economic hardship—obesity, uncontrolled high blood pressure and diabetes, untreated tooth decay in children and severe periodontitis in adults—are widespread among the patients at Eisner and Mattapan. That’s why the team approach works, says Jean-Mary. “If a patient’s blood pressure is through the roof [when they come in for a dental appointment], rather than say ‘Go call your primary-care physician,’ we can send them [to see the doctor] right away,” she notes.

Pham is using the Eisner’s role as a health-care home in Los Angeles to tackle one of the region’s most pressing public health issues: diabetes. Three years ago, Pham secured a grant from the UniHealth Foundation, a private, L.A.-based health-care philanthropy group, to add a periodontist to the Eisner dental staff because diabetics are at higher risk for gum disease.

Working with her colleagues in the medical clinic, periodontist Tzu-Lin “Carol” Chen enrolls diabetic patients with gum disease into her full-service program, which includes medical and dental care and 10 hours of education about diabetes, nutrition and oral health. Once patients get their diabetes under control, Chen provides whatever periodontal care they need. The goal of the program is to determine whether this kind of coordinated care can improve patients’ ability to control their diabetes and maintain good oral health. So far, the results have been promising. As a group, patients enrolled in Chen’s program have had their blood-sugar levels decline significantly. “We’ve been pretty happy about that,” she says.

 

On the West Coast

John Pham, D99, is at home caring for the poorest families in Los Angeles

150304_15762_eisnerclinic009.jpg John Pham, D99, never planned to work in a community health center. A native of Orange County, California, he took a job at the Eisner Pediatric and Family Medical Center in Los Angeles after graduating from Tufts, thinking he’d use the experience to “get his hands wet” and “build speed” while he looked for work in a private practice. Inside of six months, though, Pham realized he liked caring for the patients at Eisner’s dental clinic. “Even if a patient doesn’t have any money, we do see them,” he says. “They really appreciate that.”

Soon, he got more involved behind the scenes. Ten years ago, he was named director of dental services. Since then, he has overseen the expansion of the dental facilities from three chairs tucked in a corner of the medical clinic to 14 chairs in their own state-of-the-art space. Now the clinic sees about 120 patients a day, six days a week.

Anna Hernandez, a vibrant 66-year-old wearing purple sneakers, has arrived for a routine cleaning. She has been a patient at the Eisner Center for a quarter of a century and recently brought her 2-year-old granddaughter in for the first time. She started coming because it’s close to home, but she kept coming because everyone always treated her well. (She gives everyone a hug on her way out the door.)

Also in the waiting room is 55-year-old Rodney, who is diabetic (he didn’t want his last name used). An American Indian, he’s entitled to free dental care through the Indian Health Services, but he comes to the Eisner Center for the program in oral health and diabetes education Pham started. He likes the clinic so much he started bringing his wife and daughter for their dental care, too.

“This is a good place,” he says. “I feel like they really help you.”

Health Care and Poverty

Most of the patients who come through these doors are from racial and ethnic minorities. They’re also poor. Los Angeles County has the highest poverty rate in the country, according to 2012 Census Bureau figures. Nearly half the patients at the Eisner Center have no health insurance; those who do are covered by Medicaid or a state program. A 2011 study found poor, migrant and minority children in L.A. have some of the worst tooth decay in the nation, even compared to other disadvantaged children living elsewhere.

The no-show rate at Eisner is high, says Pham, who notes that 30 to 40 patients scheduled for appointments each day never get there. That’s a testament to the enduring challenges of living in poverty. For many low-income families, just getting to the doctor or dentist is daunting. It means missing time from work or school, battling L.A.’s notorious traffic or depending on sometimes unreliable public transportation to cross the sprawling city.

Pham’s knack for teamwork and innovation has earned him—and dentistry—a seat at the table.

“For kids, it’s time out of school. That’s why we decided to bring it to them,” Pham says of the school-based mobile dental clinic he helped roll out in one city elementary school. The program is slated to expand to a second elementary school this fall. “It’s not just screening or exams,” says Pham. “We’re doing everything from fillings to extractions. Parents really like it.”

It’s one of several programs Pham has started or expanded at the Eisner Center. As part of the “Zero-to-Five” program, paid for by a grant from the state-funded L.A. Care Health Plan, which provides coverage to Los Angeles County’s low-income residents, he’s also collaborated with his colleagues in the women’s health clinic to refer new mothers to the pediatric dental clinics as early as possible.

In addition to launching a periodontal program to help diabetic patients who are at risk for gum disease, Pham has also brought in an orthodontist. He’d like to add other specialties, too. First, though, he says he could double the dental staff and maybe just about accommodate the unmet need in the community surrounding the Eisner Center, just a few blocks away from L.A.’s Skid Row.

He may just do that. His knack for teamwork and innovation has earned him—and dentistry—a seat at the table.

“It’s a challenge to have medical people understand how important dentistry is,” says Denis Weintraub, DG75, DG80, clinical chief of dentistry at Cedars-Sinai Hospital, which sends its general practice residency students to train at the Eisner. “John certainly has confidence of people here. They are so happy with dentistry here, they look at him and say, ‘Whatever you think, John.’ ” —Jacqueline Mitchell

 

On the East Coast

Betty Jean Mary, D94, uses her business acumen to improve patient care in Boston

150313_15762_mattapan315.jpg

One of the first things Betty Jean-Mary, D94, did when she became dental director at the Mattapan Community Health Center was tighten up the schedule. It used to be that if a patient were booked from 10 to 10:30 a.m., the next patient might be offered a spot at 11, leaving a comfortable cushion in between. “At the end of the day, that could add up to two patients who were not seen,” she says. “Two patients a day times four doctors and two hygienists, that’s 60 patients a week. That’s a big difference.”

So Jean-Mary had the front desk start removing the gaps. Sometimes that means juggling two patients, such as tending to an emergency case while a dental assistant is finishing X-rays on a new patient. The result is that patients who used to have to wait eight to 12 weeks for a non-emergency appointment are now seen within four weeks.

“Treating more of the community—that is what success is to us,” she says.

Jean-Mary spent two decades in private practice, 14 of them running her own office in Cambridge, Massachusetts. Now she is bringing those private-practice skills to a community dental clinic.

“In a private practice, if you don’t work, you don’t eat,” she says. “The way you run your office has to pay you, but more importantly it has to pay your staff.”

To cut down on the number of the rejected insurance claims she gets on her desk each week, she has begun instructing her staff dentists about the intricacies of public health insurance, which is more complicated than private coverage. She is trying to transfer other small business management techniques to the health center.The changes seem to have made an impact. The clinic’s revenues are up 22 percent since 2013.

Unexpected Direction

Running a community dental clinic was never in Jean-Mary’s plans. As an undergraduate, she considered medical school, and spent four years working weekends as a medical transcriber at Massachusetts General Hospital. But she soon realized that route was not for her. She decided on dental school.

“I am sure that I would have been a fine physician,” she says now, “but dentistry is what I was born to do.”

For 10 years Jean-Mary took part in an annual dental mission trip to care for underserved populations in Jamaica. She made a similar trip when the earthquake struck Haiti in 2010. Jean-Mary, whose family emigrated from Haiti when she was 4, wanted to do more to help her fellow Haitians, but she could go on only so many mission trips. When a friend forwarded an email saying the health center in Mattapan was looking for dentists, she applied. It was only later that she discovered the center’s patients are largely immigrants of Caribbean origin.

“I don’t have to get on a plane to go to Port-au-Prince,” she thought. “I can just go to Mattapan Square.” She interviewed at the clinic, making it clear that she was only interested in a part-time position. She wanted to give back, yes, but she still had her practice to run.

“Treating more of the community—that is what success is to us.” Betty Jean-Mary

But soon after starting as a staff dentist in November 2012, Jean-Mary fell in love with the community health center. “I feel very needed here by my patients. I feel very appreciated. When the patient walks out and tells you that they pray for you every day, there is no price that can be put on that.”

So in May 2013, when the acting dental director and the other staff dentist both left the health center, she knew what she had to do. “Everything happens for a reason,” says Jean-Mary, a devout Christian. “My coming here and becoming dental director at the time I did—something higher had a hand in all that.” It has been a major life change, working 40 hours a week at the health center in addition to keeping up her practice in Cambridge, where she still has a staff and sees patients herself one day a week.

“You can tell she cares a lot,” says Jenny Kusner, D13, one of three Tufts graduates Jean-Mary hired as staff dentists at the Mattapan clinic. She points out that when the dentists saw how many extractions they were doing (all too common in community dentistry), and how many patients with impacted molars they were referring elsewhere, Jean-Mary started campaigning to bring on an oral surgeon.

Some of their patients have never been to a dentist, or have never been to one in the United States. Kusner has had patients cry because they are so embarrassed by the state of their mouths. “I’m almost 30, and so many of the patients are my age and younger and missing half of their teeth. It kills me to be making dentures for these patients.” Yet when she can get them to make significant changes to stave off additional problems, she says it is the most gratifying part of her job.

Jean-Mary has learned a thing or two from Azzie Young, the president and chief executive officer of the center. Young was the driving force behind the construction of a new home for the 40-year-old health center. Bolstered by a chunk of federal stimulus money, and Young’s political persistence, the current $34 million, 50,000-square-foot facility opened in September 2012.

“I have learned an enormous amount from her mentoring,” Jean-Mary says. —Julie Flaherty

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