A Reason To SMILE(S): Dental Care for Thousands of Coloradans

The Spanning Miles in Linking Everyone to Services (SMILES) Dental Project has delivered care to more than 2,300 unserved and underserved Coloradans.

That is great news for the kids of our state, for families transitioning out of homelessness, for adults with mental illness, and for other people who are vulnerable. At CHI, we’ve seen this groundbreaking initiative grow from exploratory meetings four years ago into a unique pilot program that is making a real difference in the oral health of Coloradans of all ages.

Some background: SMILES, a five-year, $4.7 million initiative funded by the Caring for Colorado Foundation and the Colorado Health Foundation, brings preventive and early intervention dental services to low-income and isolated Coloradans through five participating organizations.

SMILES relies on registered dental hygienists to deliver care under the supervision of a dentist. But here’s the big idea: The dentist may be miles away and the connection is made using telehealth technology. Colorado is only the second state in the nation to test this Virtual Dental Home model.

A few highlights of what SMILES has accomplished since it began in 2015:

  • More than 2,300 dental visits in 12 counties;
  • More than half of the patients had not seen a dental professional in more than a year, and 10 percent had never seen one.
  • Forty percent of the visits were return visits, meaning that SMILES is establishing a patient base and serving as a home for patients to receive regular dental care.

This continuity of care is making a difference. About half (49 percent) of new patients had untreated decay. But only about a third (37 percent) of patients who had already seen a SMILES provider had untreated decay.

SMILES has overcome significant hurdles in its short life, including successfully supporting state-level policy change that expanded the scope of work for registered dental hygienists.

Health Policy in Action

Several CHI staff attended a recent meeting that highlighted the progress made by SMILES. On one hand, it was just a progress report for SMILES. On the other, it was a remarkable glimpse of health policy in action, and the process involved in making the program a reality.

When we got back to the office, we started thinking about the elements that had made it possible for SMILES to make such impressive progress. We landed on these five key ingredients.

  1. A Master Chef

It takes determination, vision, and a champion to see a project like SMILES through. Linda Reiner, Vice President of Caring for Colorado Foundation, has worked tirelessly to shape the SMILES program, and without her commitment and drive, it would not be the success it is today. Caring for Colorado Foundation brought together legislators, foundations, and providers with the common interest of delivering dental care to underserved areas of Colorado. In doing so, this coalition proved that when foundations invest in innovative solutions to issues they care passionately about it can make all the difference for Colorado. Together with the project director, Colleen Lampron, Linda and the team at Caring for Colorado Foundation continue to drive SMILES and hope to expand it to other areas of the state.

  1.  A Recipe for Success

SMILES is an evidence-based program based on a framework that has been successful in California. Dr. Paul Glassman from the University of the Pacific started a successful Virtual Dental Home model which, like SMILES, uses teledentistry to treat underserved individuals who might have difficulty making it to a dentist’s office. A six-year study of the project showed that not only did it deliver cheaper care per patient than California’s traditional public dental insurance, but that approximately two thirds of children’s visits and half of seniors’ visits could be handled without ever having to see a dentist in person – saving time and money for patients and providers. The model has since been expanded to more than 50 schools, nursing homes, and community centers across California, and prompted Oregon, Hawaii, and Colorado to pilot similar programs.

  1. A Dozen Hungry Customers

Of course, vision and evidence mean nothing if providers and communities don’t buy into your initiative. And getting communities on board is no easy task. The SMILES team laid the groundwork for collaboration by holding statewide stakeholder forums and garnering grassroots support from dental practices and community groups to get the program up and running. CHI participated in these forums and saw enthusiasm for the initiative, but also the sober recognition of the legislative and regulatory obstacles that stood in the way.

Five organizations accepted the challenge and are implementing SMILES across a dozen counties:

  • Dental Aid in Boulder County provides services to high-need adults in mental health centers, nursing homes and community centers.
  • Summit Community Care Clinic, based in Frisco, has clinics for school-age children in Lake, Park, and Summit counties.
  • Salud Family Health Centers partners with Morgan County schools to serve elementary school students, and serves patients from Sedgwick, Phillips, and Yuma counties.
  • Tri-County Health Network has two elementary school sites in Montrose and San Miguel counties.
  • Mountain Family Health Centers, based in Glenwood Springs, provides services for preschool through 12th grade students in Parachute and Avon on the Western Slope.
  1. Mix Well

Implementing SMILES meant doing the hard work of bringing together policymakers from both sides of the aisle. State law needed to change for the registered dental hygienists to take on their crucial new roles. But some dentists objected. Critics said that giving dental hygienists an expanded their scope of care could remove dentists from the equation and threaten quality of care.

However, working alongside providers and legislators, the SMILES Dental Project achieved a major milestone when House Bill 15-1309 passed with bipartisan support. HB15-1309 expands the scope of what dental hygienists could do and specifically allows them to perform interim therapeutic restorations (ITRs) under the authority and supervision (via teledentistry) of a licensed dentist. (For more information on ITRs, check out Sara Schmitt’s blog here.) The legislation also included a provision allowing Medicaid and the Children’s Health Program to pay for the procedure. This was essential because it allowed dental hygienists and dental offices to be reimbursed for their teledentistry work through the SMILES Dental Project project.

  1. The Taste Test

When everything is said and done, it is important to do a taste test to make sure your initiative is ready to be served on a large scale. Evaluation has been a key element of SMILES Dental Project from the beginning and will be essential to its long-term success. By tracking metrics like preventative visits and untreated tooth decay over time, SMILES hopes to show that providing better access to care through teledentistry leads to less disease and healthier mouths across Colorado. And by tracking direct project expenses versus revenue, they hope to prove that the model can be carried out in a sustainable way in communities across the state.

The SMILES Dental Project has not only offered better access to care, but also improved the oral health of underserved individuals and communities. Funding for the pilot ends in September 2019, but sustainability plans are already in the works to ensure that these clinics continue to provide much-needed care.

All these ingredients were critical for making SMILES a reality. We at CHI love to talk about policy, but it’s particularly rewarding when we see policy become action. While the SMILES team make it look easy, a lot went on behind the curtain to make this initiative a success. SMILES provides a great recipe for other initiatives that seek to innovate and push the boundaries to improve the health of Coloradans.

Congratulations to all involved for having the initiative and drive to make this idea a reality.

To get in touch with Linda Reiner or Colleen Lampron, or to learn more about SMILES Dental Project, visit Caring for Colorado’s SMILES project page here.

Find Ian Pelto on Twitter: @CHI_Pelto

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