1999: Minnesota Medicaid Dental Innovations- Infrastructure Developments

As required by [Minnesota] statute, the Department of Human Services (DHS), which oversees the Medicaid program, [known in Minnesota as Medical Assistance] developed a number of legislative reports analyzing dental access problems and possible solutions. The first report, completed in 1999, described a number of efforts beginning in the early 1990s to identify access barriers with a focus on reimbursement and specified a number of possible solutions for expanding access in public programs.

In December 1999, per legislation passed earlier in the year, DHS convened a Dental Access Advisory Committee (DAAC). The group helped to develop a report that was presented to the legislature in January 2001, containing numerous recommendations for policy and legislative change, a number of which were implemented.

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2001: Legislation

Legislation passed in 2001 requiring DHS to convene another DAAC to "monitor purchasing, administration, and coverage of dental care services to ensure access and quality" and to prepare a report to be presented to the legislature in 2003.

Enacted in 2001, it was MN Statute 150A.10 subd 1a, Limited Authorization for Dental Hygienists that guided what has come to be referred to as "collaborative dental hygiene practice." The initial language authorized dental hygienists to provide oral health care services in health care facilities without a prior dentist's examination of the patient, if clinical experience requirements were met and there was a written collaborative agreement with a licensed dentist who accepts responsibility for the services of the dental hygienist.

The dental hygienist working in this capacity extends the provision of primary oral health care to settings other than a traditional private practice dental office. A collaborative practice dental hygienist may be employed or engaged by a health care facility or non-profit entity to provide complete dental hygiene scope of practice care under general supervision to persons who have difficulty accessing oral health care services.

Following revisions in 2003 and 2006 that strengthened the original statute, this professional opportunity for dental hygienists provides effective, productive access to oral health care for a growing population. Additionally, a dentist who enters into a collaborative practice relationship may, if they so choose, become a source of referrals for follow up treatment and possibility to establish a "dental home" for underserved Minnesotans.

Anecdotal reports indicated there were very few collaborative agreements created during the years immediately following enactment of the statute. The primary reasons for the low level of participation may have been that the 2001 legislation limited dental hygienists to providing only a portion of their full scope of practice.

The application of sealants without a prior examination by a dentists was not permitted at the time, and services could be rendered only in settings or programs where children were unlikely to reside or attend. Most importantly, dental hygienists and dentists had no prior experience in formulating a collaborative dental hygienist/dentist practice relationship which caused hesitency to do so. An analogy of this outcome commonly stated by dental hygiene leadership has been:

"The destination was chosen, a sketchy road map was drawn, but no one was behind the wheel".

During this same time period, another issue that likely delayed implementation of collaborative dental hygiene programs was discussion within the MN Board of Dentistry resulting in authorization for restorative expanded functions for dental hygienists and dental assistants, i.e. placement of dental restorations (see 2003). Many professionals thought that "collaborative practice" meant authorization for allied staff to perform restorative functions in either private practice or public health dental settings. Following passage of the Restorative Expanded Functions law, it became evident that clarity was needed to describe restorative functions as totally separate from collaborative dental hygiene practice. To date, this confusion is still a notable factor when discussing and promoting creation of collaborative agreements.

To promote understanding of collaborative practice, Normandale Community College dental hygiene program leadership, in addition to several knowledgeable, enthusiastic dental hygienists and dentists, spearheaded a series of successful forums, quarterly Q & A sessions, creation of this Collaborative Dental Hygiene Practice web site, in addition to frequent and on-going communication for persons seeking information about this new professional opportunity.

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2002: Dental Access Advisory Committee Continues

A Dental Access Advisory Committee was again formed by DHS to monitor the administration of the state's public dental care programs and to make recommendations for improving access to quality care. Membership included many of the original members, including representatives of metro area and non-metro area general dentists, oral surgeons, pediatric dentists, dental hygienists, Minnesota State Colleges and Universities (MnSCU) dental hygiene programs, community clinics, client advocacy, public health, Head Start, health plans, University of Minnesota School of Dentistry and dental hygiene, and the Minnesota Department of Health.

2003: MN Statute 150A.10 subd 4, Restorative Procedures was authorized (see 2001)

2003: School Authority and Head Start program; "application of topical preventive or prophylactic agents, including fluoride varnish and pit and fissure sealants were added to MN Statute 150A.10, subd. 1a

2006: Administration of local anesthetic and nitrous oxide inhalation analgesia is added to MN Statute 150A. 10, subd. 1a

Note: In 2006 the full scope of dental hygiene practice was authorized under general supervision; collaborative agreements are not required in dental practices (solo or group) that are regularly staffed by dentists.

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- Clare Larkin RDH MEd